Hi everyone and welcome to the Elekta Investor Update 2025. Both in the audience here in Stockholm and you online. I did it because once I started when I worked at Ericsson before and I moved from my previous job at Electrolux, then I moved to Ericsson and I opened the Capital Market Day at Ericsson. It was about 15 years or 15 years ago, and I said, welcome to the Electrolux Capital Market. I did not do it wrong this time, so I had it. Welcome to Elekta's Capital Market Day. It's great to see all of you here. My name is Peter Nyquist and I've been heading up Investor Relations here since March last year. Before that obviously worked for Ericsson and before that Electrolux and a number of other Swedish blue chip companies. And there are.
Which I think is interesting, a lot of interesting resemblance. When you look at a company like Ericsson and Elekta, it is really tech to start with, but it's driven by two things. If you look at valuation, it's driven by R&D, it's driven by recurring software revenues. As you're going to hear today, these are topics and items that will be brought forward to you throughout the day in different presentations. A little bit, we were supposed to have a full loaded CMD here, but clearly with the changes in management, we decided instead to have an investor update. The purpose today is not really to present new financial targets or update. The strategy is more to go through events that we have taking place in Elekta right now.
It's a lot of things that is happening and you will hear that as well today. We will have a main session that is both in person here at Medicinska Föreningen in Stockholm. The sun is shining for you online and there is also people online. That's the main session. After the main session we will move over to our head office, Forskaren, for three deep dives, which I know some of you here will follow us to do. I will give you more details about that later on. I would like to start with some reflections, some feedback that I have received and I think Martin together in my team and Jonas and Tobias, when we have met investors, not just only recently, but out the last months here.
I think there are a couple of things that always comes back and one is really that the gross margin we presented here in Q4 that is improving is not sustainable. I think you will see today, not at least in Tobias's presentation, a clear bridge how we actually return to pandemic level + 40% in gross margin through volume growth, through price increases, mix improvements, and productivity. That is going to be important in today's presentations. Another thing that comes back, which I understand, is really the launch of Evo, in particular in the U.S., that the delay we have now with FDA will jeopardize the whole strategy in the U.S. for Elekta. I think what you will see here today is we have control over that process. Jonas will talk about it shortly. It is also not only Evo in the U.S., it is not only Linacs in the U.S.
We have a very profitable and growing business through a brachy, neuro, and software business. We'll come back to that as well during the day. Also remember, which I think is important, we had the best Q4 gross margin ever in the history of Elekta without having a U.S. business performing. I think that's important. Even more important, maybe, wherever Evo has been launched, and particularly in Europe, it is a success. Remember that. Another thing that comes back in discussions we do have is the future of the software business. It's not going to be sustainable. You're not going to see that growing. I think today, both here and in the deep dives that we're going to have later on, you're going to understand the traction we have with Elekta ONE right now.
Also coming back again, which is very important, is really that we had 20% growth revenue software last year. A lot of that happened in Q4. I think that also provides you with a good development this year. Another thing I think has been highlighted today is the order review that we have done. We have a lot of discussions with investors. They have questioned the quality of the order book and we present today a review of the order book. The purpose of that is to cancel non-accretive orders to increase the profitability of Elekta, but also increase the forecastability. We know what's going to happen going forward. I think that's important. We're going to have a lot of things about that. Tobias is talking about that, how people talk about that, how we've done that, how it looks like.
Coming back to, I think I need a pointer to be honest. If you do not want to hear, coming back to today's e vent.
We will start then with introduction from you. Jonas will enter the stage after me here and then Tobias is going to be the third speaker. Then we have a short break, a coffee break for about 50 minutes. We will then continue with the commercial execution, where audiobooks will be one of the topics, but also the strategy in U.S. with Habib Nehmé, who's going to talk as our Chief Commercial Officer about the strategy. We're going to have Ardie Ermerss from Seattle, so he's not going to be here, so we're going to connect him. He will talk about Americas. Then we'll move to personalization and productivity, to the product side and where we have Christopher Busch talking about software solutions for Linac and software solutions. Then we have John Lapré, who's the President of Brachy and Neuro. Then we'll have Q & A.
We will have a few closing remarks by Jonas as we end this. Just before I hand over to you, Jonas, we will start the second part of this session at 16:20. Back again, as I said, at Forskaren, we will have three deep dives. One about software with Anish Patankar , who is the Head of Software. We will have one called Clinical development of Elekta Unity with John Christodouleas, who is here in the audience, I think as well. We will have the possibility to visit our Gamma Knife that we have in the building, which will be led by Head of Neuro, Caroline Leksell Cooke . We will end the day with mingle and dinner. That is it for today from my side. Any interactions with that, I would like to hand over the word to Jonas. I guess you need this.
Yes, please. Thank you, Peter. Warmly welcome everyone and warmly welcome the participants online as well. I would then, as CEO, like to kick off this meeting. We are here at Medicinska Föreningen and we will soon transition to our relatively new office. We have been in this office for a year and a half and I am really looking forward to show you the office for the ones that have not been there. I hope that you will be able to join us. A bit of news from yesterday. The Board has conducted their search process and finalized that yesterday evening. I guess you have all seen the announcement. It has been my privilege to be part of that process and I am super pleased that Jacob is able to join us. I think he is a great fit for Elekta.
First of all, his track record really driving a profitable business, but also from a culture perspective, it's a very, very good fit for the company. I'm feeling super comfortable with having him in the leader seat. There then, a few words of the team presenting here. First, myself, I have met some of you, but not all of you. I've been with the company for 20 years and have been in different roles in the company. I'm a trained lawyer from the start and then I've been having a large number of corporate functions in my latest role. I know Elekta, I know the products inside out. I know maybe at least half of the employees in person. I know many of the customers. I know the challenges that we have had over the years and I also know our strengths.
We will have Tobias doing the financial update. I think most of you have met Tobias. As we said before, we will focus a bit on commercial execution with Habib and Ardie presenting. We will focus more on the product side with John and Christopher presenting. Christopher, take a few minutes with him. He is relatively new in his role, but not new at Elekta. I am super pleased to work with Christopher. It is going very, very well with great focus on deliverables and the product roadmap. First of all, going a bit back in the history, and this is basically a reiteration of the earnings call. We are very, very proud of this and very pleased of this. I think someone said that no one really expected that for the fourth quarter. We have a very strong gross margin.
That is, I'm particularly proud of that. I think it's, as Peter said, it's the strongest gross margin since 2017. There you see that the programs that we implemented, the price increases, the product mix, and the new products and so on are really starting to bite. We see a great improvement there. Of course, you know, the launch of Elekta Evo and Elekta ONE, we see a large momentum of those products, in particular in Europe, where it's being launched in all European countries. Now we launch it in market after market after market. Tobias will come back a bit and talk about the impairment and so on that they took as part of, at the other side of my job, so to say, the cleaning part of the job. This is a slide that we also showed on the earnings call.
The objective of this slide is to put tariff exposure a bit into perspective. China, we have a very, very local business in China. We manufacture all our products in China. The Linacs, we have software development in China. We have Brachy and Neuro products in China. The exposure is very limited. We export some parts from China to the U.S. and to Europe, but very, very limited. If you look at the exposure in the U.S. you kind of could split the business there in the U.S. in three parts. One part is service, very local, local labor and so on, dependent on spare parts that are imported but anyway for a quite nominal value considering a service contract and so on.
You have a software business in the U.S. which is completely local in the U.S. and finally you have the devices that are imported into the U.S. predominantly from the U.K. where you have a set tariff of 10%. Also good for you to know is that the tariff is applied on the transfer price of the product, you know, so that limits our exposure quite significantly. We have Gamma Knife from Sweden. However, the Cobalt comes from Canada. That is exempt from tariffs. You have the bracke of the loaders coming out of Veenendaal in the Netherlands. That is a bit to give you some more information on how we look at tariffs and so on. Also of course this is something that we work with on a daily basis because as you have seen, it's a kind of moving target.
The outlook, you saw that on the earnings call. It's unchanged for the year. You see that Q1, it's not a huge quarter for Elekta. The volumes are not as significant as in the fourth quarter and we have some on cost in the first quarter and also some FX effects. Meaning that you can't just extrapolate. I think most of you knew that anyway. You can't just extrapolate Q4 on Q1. Full year, kind of bullish for the full year. We believe that we have our business under control. We will handle these conditions and we put great trust in our price increases and the new product launches. You have the mid term guidance with 14% EBIT and pre- pandemic levels. Pre- pandemic levels could or should mean over 40% with respect to gross margin. This is one slide that I would like to spend some time.
It's actually my favorite slide in the pack here. What are we trying to say here? We say that we operate in a financially very, very sound environment. You know, this is kind of. It's a very attractive industry. If you look at this. You know, we are working in a growing market. Many persons today, they don't get cancer only once in life. They may get it twice or three times. Scanning is getting better and so on. The underlying market is constantly growing. We are working in a very, very consolidated market. On the Linac side it's basically a duopoly. It's we and Siemens Healthineers and on the Brachy and Neuro side, we are clear market leaders in those segments as well. If you look at Brachy, very consolidated Gamma Knife, we're basically alone.
Even though there are some new entrants and so on coming into that market. It's not that easy to start a company in this market. The barriers to entrance are enormously high. First of all, you know, it's quite complicated. Products that we work with with high safety requirements and also the regulatory hurdles to get into the market is enormously high with large demands on the quality system, with large demands on regulatory filings and so on. If you look at the business as such, it's a bit of an asset light business. That's a bit of a mind shift as well. You know, we look at our install base, we look at our service, our software and our capability to upsell to the pretty large install base. I will show you a slide on that later.
Finally, going to the install base here with, as I mentioned, pretty large possibilities to upsell to it. Then what have we done? We have not been sitting still, you know, as you have heard, you know, we have reviewed our balance sheet, you know, and looked at our capitalized R&D. Tobias will tell you a bit more about that. You also saw today that we have reviewed our order book quite significantly. What is the purpose of that, going through every order that we have there and so on? It is to make sure that the orders are profitable. That is why we review the orders. We have quite a long time between order intake and revenue. We need to make sure that the orders we have in our backlog are profitable, hence the order review. We have not been able to cancel out everything, so there may still be some orders, you know, because it is binding and so on.
The orders we've been able to attack, we have attacked them. Of course, leverage on our R&D investment, which I said a bit before, you know, to leverage on our upgrades, our software, our services. Also, what is good for you to know is that we see a bit of a shift in the company. Christopher will come to that. It's less big iron today. It's way much more incremental development. Smaller upgrade orders, smaller capabilities, smaller SaaS offerings and so on to upsell to the installed base. Of course, you know, profit and growth. Evo and Iris product mix improvement. Completely establish a new price segment for the products. Enormously efficient to launch new products with new functionality in the market.
Of course, you know, to leverage our strong, you know, we are really strong in Europe and brachy and to leverage that market leader position and its high margin segments as well. Of course we have constantly worked with price increases. There is more to do and we are constantly monitoring it. We're working to increase prices, we implemented price controls and so on. It's a bit of a cultural shift in the company as well. Today we take profitable orders, we don't take unprofitable orders. Growing the market is not everything for us. As Peter said, we have changed our submission strategy in the U.S.
Together with the FDA, we have discussed it through and then have come to a conclusion to change the strategy because it will go faster with the new strategy rather than the old one. We have done that now and we knock on wood, hope to get approval sometime after the FDA has reviewed our submission. There also, you know, a bit like Peter said, we deliver very, very strong quarter, but we do not have Evo approved in the U.S. You know, it is a bit icing on the cake as I see it. You know, then hopefully we can get the same traction that we have in Europe with Evo launched in the U.S. This is the strategy that we have been living with for quite a while.
We end that strategy now and going into more an interim year, it would not be fair to launch a new strategy when we have a new CEO joining the company and so on. Now we have an interim strategy. First I would like to close off the 2025 strategy a bit and tell you a bit of what we have gained out of that strategy. First of all, we have spent a lot of time and a lot of money to develop our products, you know, and now we have a really solid foundation. We are adaptive across all our product segment, leading to quite much more efficient treatment, less staff time and of course a huge patient benefit as well. You know, that does not have to go back and forth through clinic and so on.
Very much directed towards efficiency, shortening treatments, time and so on. You will see a bit of that when we go back to Forskaren. And then also, you know, I would like to iterate again smaller incremental development projects with the capability to upsell to the installed base. This is also a good slide. Here you see, and it kind of separates us a bit from competition and so on. Here you see a cancer clinic as we would prefer to see a cancer clinic. You know, not every clinic looks like it, but some do. You know, here you see that we cover the entire spectrum in the cancer clinic and you have it from the cloud solutions that we provide, the brachytherapy solutions that we provide.
You have the patient handling the oncology informatics system and then of course the treatment modalities with the Elekta Esprit or Gamma Knife. Our new product, Elekta Evo Harmony, which is more throughput product and so on. Of course the gold standard for adaptive Elekta Unity. This is another key takeaway from our Access 2025 strategy. It provided us with a huge install base, that same install base now where we have possibilities to use that, you know, to upsell and upgrade, then to focus a bit on what we call the interim strategy. This is what we will work with during my tenure and during this year. Really, really strong focus on profitability and the transaction. We just get rid of everything else, you know, with strong focus from the company and we control what we can control.
We, as I mentioned, we increase our focus on profitability, profitable markets and of course traffic driving price increases, which is necessary in this landscape that we have around us today. That will then get us to the pre-pandemic level and an EBIT margin of 14%. Thank you.
Well done.
Hello everyone. A big warm welcome here to Stockholm again and third presenter saying that. My name is Tobias Hägglöv. I've been running as the CFO in Elekta here for the last three and a half years. I have throughout my career spent my time in various leading roles within finance and all of my recent roles, both as CFO as well as group controller for sizeable companies. We have been able to deliver margin expansion and I'm absolutely convinced that we can do that here in Elekta as well. You heard here from Jonas and Peter. We're coming out really strong from a Q4. We delivered the highest gross margin for being in Q4 for the last five years. Maybe more important, which I think alluded a bit to Jonas, was that it was not a coincidence.
It was based on our strategy, it was based on what we want to do. Today I will share some more light on this and how we think moving ahead to drive the margin forward. I will then cover here in three blocks. I will start here, what I just mentioned, talk about how to improve the profitability and the emphasis and importance of a gross margin expansion. Then I will talk about R&D on the balance sheet and I will end up here with some findings about capital allocations and how we think upon that. Starting here with how to improve profitability, firstly, I would like to echo here what Jonas said. This is a good industry to operate in. It is a growing industry, it is a consolidated industry with few players.
We also see here that just as Jonas mentioned that the barriers to entry are high. Regulatory aspects, safety aspects, technological aspects, and also from a commercial point of view that you as a customer, if you have chosen an Elekta solution, you actually tend to choose an Elekta solution. Again, with that said, our gross margin development here over the years has not been favorable. We have seen a deterioration here over the years and even though you might say that from somewhere 2021, 2022, it has been relatively stable, it is still not good enough. Clearly when we look at ourselves, we see we need to improve from here and that we will do. I think from the presentations today you will also find why Elekta is better equipped to do this than what we have been over the last years.
One important aspect is here that and we will talk about R&D, but there has been a need for product development, for shaping up our competitive edge both in terms of market position, but also being able to get the value here in terms of higher prices from our customers. The gross margin development here has also been a consequence of that. Elekta has very successfully been able to broaden its installed base and really capture the growth in emerging markets. A lot of greenfield where the price points have been lower. It has also, as you see here on the slide, been that we were hit first by supply chain challenges followed by high inflation, especially on niche components into our products where we did not really fully compensate this by rolling it over to the customers in the form of price increases.
However, looking where we are now and again coming back to Q4, we see this is a major step to bring back the financial development to place where we should be and here today. I will now walk you through here the four basis blocks. I will talk about the volume growth. I will talk about the price increases that Jonas mentioned and that we really firmly hear both in our management team but started also to change throughout the organizations. Our driving mix improvement coming here from we talked about the product launches. I will also share some lights on how we think on the high margin businesses. You will hear Christopher and later Anish share some light on the software. You will also hear John Lapré here talking about the new Rembracke products.
Essentially we have a very strong competitive position and we can use this both to drive revenues as such, but maybe more important to raise the profitability. The final aspect here is productivity that we need to have in our DNA to run here. Finding that extra productivity and focus here will change a little bit over the next coming years. I will come back on this one. It is also to get more leverage on the gross margin expansion. Starting here with volume contribution and volume growth, we have a very comprehensive product portfolio. It is further strengthened here by the new products that we just launched here to market. We are at the beginning of a launch phase. We see a strong traction in Europe.
We will work through here, the FDA clearance in the U.S. and we see markets such as China which are recovering and the launch that we are on that will expand here on the global base. Jonas, you were also alluding here to just the installed base and opportunities that we see here. We have, excluding our brachy products, more than 5,500 solutions out there that we can upsell, cross-sell and utilize to drive software growth and to drive more service revenue. If we would include the brachy business here, it will actually add up to 7,500 which you will cover here later, Habib. This is a great opportunity both to drive the revenues and also with a focus here, not just grow. I think here today's announcement, and I will come back on that in how we manage the backlog, it's the same theme.
It's to drive a profitable growth ahead of us. We do have a strong backlog. We actually currently have a backlog here of approximately SEK 37 billion. Many of you saw the announcement here today. I would really state that this is to enforce profitable growth moving ahead. What we have done is to address non-accretive orders, orders with lower profitability than average. Some of them have also been loss making. This we have addressed and this is fundamental. If we're going to drive the profitable growth and really mean what we say, then we also need to proactively work with the backlog and create a more healthy backlog. We do have macroeconomic uncertainties and certain things have changed here over the years. I received here. Have you received a lot of strong customer reactions. We have not done that.
It is essential for us and it is healthy to look at what value we will deliver to our shareholders in terms of higher profits. What you also see here is that this is nominated in Swiss Krono. Part of this is just a mathematical exercise that the value of backlog nominated in U.S. dollar, euro, and pound is actually less worth in Swiss Krono. That is just a currency development. In the year we delivered a book-to-bill ratio of 1.09, we came out from a Q4 and there were some questions about the orders. Again, I think that in Q4 we could recognize a book-to-bill of 1.12, clearly above 1 to fund future revenues. What we also see in this number is the momentum for our products, the recovery in China, and it is actually also including a weak U.S. development.
Currently Elekta is not only us, but of course with FDA clearance in the U.S. that will create an even better platform for future development pricing. Jonas was alluding to this. Our price increases in order they will continue. This is tedious work. This is a work that you never can let go. I rarely been in a company where it's actually applauded by a sales organization to raise prices. For us it has also been a bit of a culture shift here. What we have done and what we will continue to do is that an increased focus on profitability. We have built up under Yoli D. Habib a pricing office, a structure here for industrialized a more effective method to go with price increases. The price increases currently are clearly higher on orders than the revenues supporting again the margin profile in the backlog.
That work will continue. We have also changed the sales incentives here, moving a bit from volumes to more on profitability, including then price levels. When we talk about mix, we will run this in two aspects. First of all, looking at the product dimension in our plan and how we will drive the business is really to enforce a larger share of high margin products throughout the year, which I also will come back to. You heard Jonas. Here we could recognize clearly a higher growth for software of 7% compared to the 1% as a group in total. On revenues on orders, we could actually recognize a growth more than 20%. That work will continue here into the years to come. Service again, the install base opportunities to upsell and use our service offering very intelligently to provide more value to the customers.
By doing so we can also then enhance the value and also the financial value and also margin expansion. When we look at the market mix and geographical point of view, it is of course the FDA clearance in the U.S. but it's also to continue to build on the momentum here that we are on in Europe. I will share later on that 60% of the orders in the second half in Europe of Linac orders were actually related to Elekta Evo. Another aspect to combine the geographical point of view with the product point of view. Finally here, China, as most of you know, a little bit less than two years ago, it started an anti-corruption campaign in China. It led to a huge order drop within the public segment of China, which stands for 70%-80% of the market.
That also led to pressure on the revenue. What we see now in China is a recovery of the Chinese market. We have actually passed now. The orders are higher than the revenues. We are running now in China with a book-to-bill above one. That is also something that we will utilize now. Moving ahead, if you then look into software a little bit more in detail, on the left-hand side, you see that the software development over the last years has been quite stable, except for the last year where you actually can see that the share of revenue coming from software has increased. More than 20% of our business is actually related to software. More than 2,500 clinics worldwide are using Elekta solutions.
When you look at the split, two-thirds are coming from oncology information and one-third from drug treatment planning. Looking a little bit more here in terms of contribution from a financial point of view, I talked about that we could see an order growth above 20% in the last fiscal year in terms of orders that will be reflected in higher revenues. Moving ahead, more than 25% of the OIS orders actually relates to SaaS software as a service. This is quite interesting because on average you get 80% more value by arranging a solution like this compared to a point of sale. It will also create a smoother trajectory of the revenue stream and that will of course enable a better resource allocation and also higher predictability productivity. This is something that we will constantly drive and constantly crunch out from our operations.
The focus here will change a bit. You have seen over the last years here that we have successfully implemented two cost reduction initiatives. A larger one during 2022-2023 and a fairly sizable one also in the last fiscal year. It has been across the P&L. We have taken out costs both within COGS, within R&D, and also within SG&A. Moving ahead, I think here we do have a great opportunity to leverage more on the COGS aspects and then again support gross margin development. When you think about the COGS of Elekta, some areas are quite similar to a standard industrialized industry company, but some of them are also a little bit different. When you look at the procurement, this is something that many companies do and we will do that as well.
Optimize the supply chain work here with smarter procurement deals and getting leverage from that. It will also be to work through here what says here a simplified and accelerated order to cash projects. Really, how do we most effectively complete our projects running with an order fulfillment, as we say, process. Really from the order point of view until we have collected cash, a big focus on that now in Elekta to make it more effective. We also, when it comes to service, which is another area here, see opportunity by investing in digital solutions to provide more remote service and by that reduce the working hours, travel time, which then also will save cost.
When it comes to the R&D aspects, and you will hear I really line here with Jonas and the great start of Christopher, how we will continue to work with, automate and streamline our R&D effort to drive COGS development as well. Of course, designing also products here for faster and easier development, deployment and upgradability. Coming back here to the upselling to the install base. These four blocks, it will be about volume growth, it will be about prices, it will be about how we enforce and drive the product mix, both purely on a product point of view, but also geographical point of view. Lastly, supported by enhanced productivity. That is how we will drive the gross margin and raise the gross margin ahead. I received a question. Okay, what do you mean with pre-pandemic levels?
What we mean is we should establish ourselves north of 40% gross margin that we will deliver upon. Shifting gears a little bit, moving on to the R&D, Jonas was mentioning this. We did in the Q4 results an impairment in a size of SEK 1.1 billion following the IFR standards. It is also a calibration of the product development roadmap. It is predominantly done within software and we have changed here from internally developed cloudware to using external supplier. Again, also connecting here to the Q4, R&D is essential for Elekta. We will benefit hugely from the investments that we do. There is a clear reason why we will continue to invest in our products.
Because it will lead to a competitive edge and a clear opportunity to also mix up both the value from the customers and the patients, but also for us in terms of higher profits and profitability. Profitability, the impairment also leads to a reduction of the increase of amortization. As we have communicated, we see higher amortization as planned here. The impairment will reduce that increase of SEK 100 million. When you then look at the different components on the R&D, we will see that the capitalization rate will go down gradually as the R&D projects that we run will gradually move into more mature phases where the share of the purely operating expense is defined then as pure cost on the P&L that will increase and the rate of capitalization will gradually go down.
All in all, this will lead then to when you look at the cash R&D, namely the gross R&D and the net R&D, which is really what you see here in the P&L in terms of the gross R&D, and you remove the capitalization, add amortization, those two will converge. This will also lead in future to better cash conversion and a higher cash flow performance, everything else equal with the same margins. It is in line also with what we want to do and how we plan the R&D projects. Some wording on capital allocation. Three areas: organic growth, selective acquisitions, and also here we have strategic partnerships and joint ventures, and finally direct return in the form of dividends. Starting here, then, organically.
If you look at actually how we use our capital, I mean a big chunk of that is going into the R&D. I think you can see here the contribution in Q4 in terms of gross margin contribution. What you will see is that in terms of share of sales, this will gradually go down towards a level of 10%. Still, it is quite a sizable investment. Again, it is a strict connection to drive profitable growth and margin expansion. When you look into the M&A agenda and the strategic partnerships and joint venture, we will leverage what we have done starting here with recent strategic partnerships. I mean you have seen the announcement here with Philips, with GE, etc.
More recently we have started to work here with Sinopharm in China, which really provides us a much better exposure to the Chinese market, especially when it comes to these tier 3-4 hospitals and cities which are a little bit more cumbersome to access just as a player. This provides us an even stronger edge in the Chinese market where we are by far number one. We have also done some strategic acquisitions. We had soft in brekkie. We have also done some investments here in the software area. What you have also seen over the years is that we have acquired distributors and the reasons for those have been twofold. One is to get a better control over the market and the customers by getting closer to the customers. It has also been a very effective method to raise the profitability in that specific country.
We have also established new offices here in key countries here, Philippines, Indonesia, Romania and moving ahead here, looking at the M & A agenda going forward, yes, we will do so. We will continuously monitor it and where we see opportunities, either to accelerate growth opportunities or to actually address specific items, either from a market point of view or a product point of view, we will do so. It is more a complement to the organic strategy because we are strong with the product offering that we have. The board recommends an unchanged dividend of SEK 2.40 per share. It is supported by a very strong Q4 cash flow moving ahead. I think it goes with our results. Also for the cash flow, we are proud of the Q4 performance, but far from satisfied.
This is at the beginning, we are in the start of a launch phase and that means we should continue to raise profits, raise profitability and as a consequence of that as well, improve the cash flow generation here as well. That will of course then be the fundamental for driving a dividend growth as well. Key takeaways here I've talked about here, I'm absolutely convinced that we will deliver on the mid term targets. It is to deliver an operating margin north of 14% and it is to bring back the gross margin to pre pandemic levels. What we mean with that is to establish ourselves of a gross margin above 40%. The way there, the route, the path will be via improved volumes. You saw the components how that play out. It will be a continuous effort on price increases.
We will utilize an enhanced mix both from a product point of view and a geographical point of view with acceleration in mature markets of course as a basis for this, also having the productivity supporting it. We have taken actions to adjust the balance sheet and you will see how the gross and net R&D will continue to convert. Finally, here we will improve our cash flow via higher earnings and we will leverage our R&D investments and that will be the support for future dividend growth. With those words, a pleasure to see you all. Thanks for me, over to you Peter.
Great, thanks Tobias. It is time for coffee. I missed out in the beginning here on some housekeeping issues. First of all, this, as you probably are aware of right now, is filmed. You have to be aware of that. You need to tell the audience that. Secondly, I guess all of you have seen that there is a Wi-Fi key guest, no security code, so you can access that. That is it on housekeeping side. I would like to have you back and also you online at 2:10 P.M. CET, so 14:10. We will start the next session at that point. Thank you. I think the whole first session was good.
Welcome back from the coffee break, you here in Stockholm. And welcome back all of you online. I heard it's around 160 people joining there as well live. That's a good number and numbers we've talked about. Now we continue with the next part, which is commercial execution and then personalization and productivity. That's going to be the next part of our session here. The first part will start by our Chief Commercial Officer, Habib, and then Ardie, as I said before, will join from Seattle. Then we have Christopher Busch as well John Lapré talking about personalization and productivity. With that, I leave the word to Habib.
Thank you, Peter.
Clicker is over there.
Yes, warm welcome everyone for the fourth time I think. Thank you for being present here either in person or online. Maybe good morning those online or good afternoon for you here. I'm Habib Nehmé . I'm the Chief Commercial Officer of Elekta since 18 months. My mandate with my team in the regions and in central marketing and central service order fulfillment, commercial excellence is to design and execute on the commercial strategy for Elekta and to deliver the profitable revenue, the profitable market share. Before joining Elekta, I was 27 years in GE Healthcare where I occupied positions, executive positions in Europe and in emerging markets. I was as well the Chief Pricing Officer of GE Healthcare International in 2008 during, you remember, the financial crisis. Pricing is something that we know a little bit how to deliver on it.
Today I'm very pleased to have been given this opportunity to talk with you and show you how the Elekta solutions are addressing customers and partners and clinicians as well as stakeholders and shareholders needs. My goal would be to walk with you through the global markets of radiotherapy and explain how Elekta is delivering in these markets. The second point, how our solutions, either on hardware or on software, combined with a strong install base globally, are reinforcing our positions or expanding our positions in this market. You know, commercial strategy without execution is useless. I want to explain to you how our commercial execution rigor is transforming the commercial operation of Elekta to deliver sustainable, predictable growth for our shareholders and for our partners. First, Elekta global presence is its core strength.
We have balanced and mixed geographical revenue coming from all around the world with gross drivers in each region. When we talk about Americas as a continent, it constitutes, it makes up 29% of Elekta revenue. U.S. stands as a high market and high value for us. And Ardie Ermerss, who is in Seattle here, will explain to you Elekta commercial approach and solutions for this market. EMEA makes up to 37% of Elekta revenue, and EMEA is Europe and Middle East and Africa. Europe is 80% of this number, and Elekta enjoys very strong position there. We will talk more about the solutions and how we win in Europe there. Nevertheless, Middle East, Africa constitute 20%, and we see very strong momentum. Elekta has a strong position in this area. Now Asia Pacific, that includes Japan and India and China, it constitutes 35% of Elekta sales.
Where China, where Elekta has a leadership position, is 40% of this market and 40% of this revenue. We will talk 40% of market share as well. India is a fast growing market where Elekta is constantly investing in this market. Overall, as we go forward, we want to keep our leadership position in China and in mature markets. We want to grow our profitable shares in the U.S. and Europe and scale our presence as we go in emerging markets. We do not have a one size fits all strategy. We tailor our commercial approach in function of the market, in function of the competitive environment, in function of our presence in this market, and in function as well of the growth perspective and reimbursement and other consideration of this market.
For example, in India, in Southeast Asia, in South America, in part of emerging China as well, where we have a strong market share, we grow in steps with the expansion of the market and we differentiate ourselves with service. I mean, Tobias, talk about service potential with growing install base. We'll see more about that in another part of developed China and in Europe. We target existing install base, existing customers, new product introduction, definitely with differentiated software and customer-centric service in the U.S., and we'll see more about it where we have a large portfolio position in Euro, in Brachy, and especially in software. We leverage this to deepen our clinical footprint in this market. Basically, in the mature market in Europe and U.S., we want to grow profitably the existence of the install base.
At the same time, as we said, we scale our presence in emerging markets. It's about precision, it's about matching our right strategy to the right market and maximizing the impact, maximizing the return and the value. Now is this sustainable and why Elekta has ingredients in its solutions to grow profitably here because we are backed by the world's most comprehensive portfolio in radiotherapy. We have the solution that fits either emerging markets or mature market. 63% of our revenues comes from mature market, 37% from emerging markets. When we look at the two segments of brachytherapy and neuroradiosurgery, we have a leadership position here. These are two specialized segments, highly defensible segment there. What you heard about the entry barrier is high there and we have leadership position there globally. When we look at our portfolio in CT-Linac and MR -Linac .
W e have the most comprehensive portfolio, adaptive ready or adaptive available, either offline or online. When we look at the CT-Linac, we have the imaging Iris, which is the artificial intelligence imaging enhance that provides the most precise auto contouring and speed for adaptive treatment when the patient is on the table and online adaptive. Now, all the investment that we did on software here is paying off. When we look at the Elekta ONE software environment, it is not only a growth engine for Elekta, but it is a productivity for our customers who are streamlining their workflow globally there in this aspect. Actually, how do we win in Europe? Let's take some example. We combine the commercial momentum with the most clinically proven portfolio. It is about commercial and about clinical value added to our customers.
We provide the most versatile, as I said, CT- Linac. We talked about the adaptive offline or online. We have the imaging-enhanced capabilities for the auto contouring there. We have the Elekta ONE suite in software that you're going to hear more about and have a deep dive with Anish on it, which is allowing to streamline the workflow and enable more complex and more advanced workflow for the customers. At the same time, when we talk about stereotactic radiosurgery or stereotactic radiotherapy either on the body or in Neuro, for example, I give the Esprit in Europe, which is a gold standard in SRS. When we talk about the brachytherapy, the Elekta Studio delivers enabled capabilities of planning in practice therapy. All this in Europe is already available, is offered, and making that we have a leadership position in Europe, this combination.
Now we go to another interesting market. China. The existence of Elekta there is back to four decades. We moved from being a supplier to a local investor. We are investing in the healthcare system of China. In 2006 we started manufacturing, look at the vision of Elekta, that's still there. We started investing in manufacturing of CT- Linac in China 2006 and actually we manufacture, we scale it to manufacture brachytherapy, neuro and as well, software. Beyond this we build strategic joint venture there, as Tobias talked about with Sinopharm, with engine in software that allow us as well to compete in all segments, either public or private. Beyond this we have a center of excellence for research and development, for innovation. We have center of excellence of clinical education that provides the values not only for China, but as well globally.
All these, I would say, actions since many years make that the customers trust Elekta in China and consider us as a local player with international and global quality standards. It allowed us to grow our install base significantly. For example, on Linac, in the last five years we grew our install base despite all the crisis by 9%. This allows us as well to keep, despite the competition, despite the drop in the market, a leadership position north of 40% of market share. China is a very important market, one of the most, I would say, important markets in the world. Elekta wants to keep the leadership position there. Why do we need to keep a leader position there? Because, I mean, China has the fundamentals of growth. Still, the density of Linac per million of inhabitants is low.
The cancer plan announced to China 230 plan favors the expansion of the Linac and access to radiotherapy in China. We want to play there. Moreover, there is an increased interest in the procedures of hypofractionations and as well adaptive radiotherapy. It aligns with our strategy, it is synchronized, it resonates and it matches our strategy there. The same thing, our and why we will win, why we'll keep winning? We do not have accidental presence. We have a structural go to market there, we have local manufacturing, we have a center of excellence, we have a strategic partnership. Therefore, we are in a very good position to keep growing there and compete either with local manufacturer or other manufacturers. The other point as well, we are delivering what the customer wants. He wants products, he wants quality and he wants trust.
Somebody who's been here for a long time. This is Elekta, so very confident about Elekta presence and strategy as we go forward there. Now we go to the solution sides and to the installed base. To show you how our growth is powered by a dual engine commercial strategy. The first one is getting new installed base, the other one is harvesting or leveraging the existing installed base. How do we get new installed base? We get installed base by delivering adaptive ready systems. I say on CT- Linac or MR-Linac and we deliver them by steps, depending on the clinical need of the customer. We can go ready adaptive to adaptive offline to adaptive online, CT- Linac, MR-Linac. This as well to match with the budgets of the customers built up.
All we talk about is software and that we can sell there or with the Evo. This is part of our value proposition. At the same time, we have an active install base. An active install base on which we can still sell upgrades, capabilities. This is building a high value relation with our customer, is building as well loyalty. It is not about selling more, it is more about having more value for the customer. That is translated into margin to Elekta as well. We have this path of the install base. Truth be said, with our Elekta 2025 Access strategy, we built a large installed base and 70% of this installed base is under service contract. What does it mean? It means that we have unmatched visibility on this install base. We know the install base, the capability, the configuration.
This allows us to structure life cycle programs to move to Flexitron, for example, in brachy, or to move to Esprit in neuro, or to move to Evo in the Linac. This is unlocking high margin revenue on the installed base. We are applying the same thing. I mean, the 7,500 includes the brachy as well, includes the neuro, it's not only the Linac, and includes the software. Out of it, you have 2,500 installed base of software, in which we are transforming into software as a service and allowing us to have a predictable high margin revenue. For example, now we started upgrading the Monaco installed base, which is the treatment planning systems, to Elekta ONE Planning, allowing more depth in the clinical capabilities and at the same time more productivity and more speed.
Recently we launched the Elekta ONE Planning on the brachytherapy to enhance the capability of planning of the brachytherapy and will follow with the neuro side. This is about the solutions and about the installed base coupled together to create this dual engine of growth. Now let's go to the commercial rigor and the execution side. You know that we are in a business to big extent besides software. Brachy is a backlog model business. It is very important to have very strong predictable and high margin order book. This is what we did in order to get this strong order backlog. We took hard decision but necessary decision to cancel non-accretive order. All in the frame of the contractual agreement with our customers. We find that actually we have a SEK 37 billion.
Of strong executable backlog where 82% of this backlog we have a plan to deliver in the coming three years. We worked around three main topics. One is how we can get the orders booked in a criteria that allow predictable transferability of the backlog. Second one, how we can get a good management of this backlog either on the profitability side or the predictability side. The third one, how we can continuously monitor this, I would say engine of growth and this is core business of the backlog and what we did. On the first side is the order quality. We make sure that we have when we book an order, we have all the criteria that give us visibility on the transferability of the backlog and we keep our salespeople engaged till this happens.
We allow all this collaboration in order to get transferable backlog. The second part is continuous monitoring of this core asset, which is a backlog. When a backlog becomes older than three years, we go back to the customers and renegotiate either prices or other conditions before taking any other decision. Actually, we found ourselves in a position where we have a strong executable backlog of SEK 37 billion divided between solutions and service. Finally, before introducing Ardie from Seattle, I want to leave you with our simple commercial strategy: retain our customers, increase their loyalty, grow our installed base. The third one boosts our services on this installed base. First, we retain them by proposing continuous upgrade and continuous improvement of the life cycle of their installed base, which creates loyalty.
Second one, grow with a new offer, go to new customers with the value proposition of adaptive and with a large portfolio. The third one, we boost this installed base or revenue. We boost our revenue through services, offer of software and other high value upgrades. Having said that, I thank you and it's my pleasure to introduce Ardie Ermers who is leading Americas from Seattle to you, Ardie.
Thank you so much, Habib, and welcome everybody. A warm welcome from Seattle. My name is Ardie Ermers, I'm the EVP for Americas based out of Atlanta. Before this, I was EVP in Europe where we were able to turn around this trajectory into positive market share gains. Now you can see obviously the impact of those wins with some very good growth out of region Europe. Before this, I was in the United States for 17 years working for a company called.
Keep going.
This is better. Sound better? Is this better?
Just a minute, just a minute. You can talk?
Yes. Turn it down. Turn it up. Is this better? Yes. The quality better. Hey, can I proceed? Yes. Okay. Yeah. Yeah. To go back, introduce myself, Ardie Ermers. I'm the EVP for Americas, based out of Atlanta, where our headquarters is based. Before this I was EVP in Europe, where we were able to change the trajectory of Elekta into positive market share gains. You see the results of that work and it's showing the positive trajectory in region Europe. Before this I was 17 years in the United States for a company called Philips. Today I'm going to share a little bit about our strategy to be more successful in region America, specifically in the U.S.A. Next slide. Just like in Europe, we see that radiotherapy is evolving, also in the U.S.A. we see that there's a heavy pressure based on the cancer burden. Our customers are looking at ways to deliver radiation in a more efficient way.
The way to do that is to really focus on a term called hyperfractionation, which is to reduce the amount of fractions and to be more accurate and more precise in delivering the dose. This trend has been started many years ago and Europe is leading the charge where also the reimbursement system has adopted to these ways of delivery. We see the same needs in the U.S. market and customers are asking us on how to do this in a more efficient way. There's also staff challenges, so people want to make sure that they can deliver this dose in a very accurate manner, but also do this with the pressure on staffing. The way to do this is to develop a new product portfolio.
What you heard today from the speakers is that we are heavily focused on adaptive radiotherapy, because adaptive radiotherapy is going to enable us to do hyperfractionation. It is going to give the tools in order to deliver this dose much more efficient and therefore being able to treat this patient in a shorter manner. Also, what is helping us here and setting us up for a good growth path is that the systems that are currently being used in the U.S. on average have a lifespan of about 14 years. That means on the older systems, people are still being treated with 30-35 fractions. You can imagine if you have cancer and you have to go to the hospital 30x-35 x for radiation treatment, that obviously is not very exciting.
The centers that are winning and that get the choice of the patient are the ones that are improving their portfolio, improving their Linac install base with systems that can handle this hyperfractionation. For us this is a great opportunity to come into the marketplace with new innovation that addresses this need. We are working currently with the FDA closely to get this solution into the marketplace and we are anticipating to have this very, very soon. Next slide, next slide. While we are working with the FDA on getting this new adaptive therapy solution into the marketplace, we're not sitting still in region Americas and specifically in the U.S. We are enjoying a fantastic market leadership position with our Brachy portfolio. Flexitron is the market leading product and Brachy is a high profit business that is really showing growth in the marketplace.
We see that especially for certain applications, especially in cervical cancer and OB-GYN. The Flexitron is the gold standard and the Brachy Boost is the standard delivery of every center in the U.S.A. We show that we are growing this marketplace together with our collaborators and see that the future for Brachy has a very strong position. We also launched a new platform called Esprit a couple of years ago and now we're seeing the fruits of that labor with very, very strong growth in the Neuro segment. Again with very, very high business, high margins. Most importantly, once we launched our new software suite called Elekta ONE Planning, we see a rapid adoption towards this new software solution. In this case, our therapy planning engine has reduced the therapy planning lead times about 80%.
Customers are really eager to adopt this Elekta ONE Planning software to make sure that they can deliver this radiation in a much more efficient way. The pipeline for Elekta ONE Planning is rapidly increasing and we see that the customers have a very strong interest in obviously benefiting from these technologies. The combination with our partner MIM, which is the gold standard in contouring, is really, really perceived very well. They have a very strong market share position in the U.S. and we're working very closely with them to delight our customers with these new software solutions. One thing that customers also ask is to make sure that we don't focus only on our traditional Linac and MR-Linac business, but that we also incorporate the other two key businesses.
We have launched now Elekta ONE Planning for brachy, which shows how we are integrating this into the software suite of the hospital. The next step will be to do the same for Neuro. As you can see on the right-hand side, this is really helping us with the profitability of the U.S.A. and the profitability for Elekta as a whole. Next slide, next slide. To show the evidence that this strategy is working, we are very proud to announce that we have now installed 30 Esprit across the U.S.A. The Gamma Knife is a very, very strong portfolio and a very strong offering for our SRS customers, and you see that the reimbursement rates in combination with the clinical efficacy of Leksell Gamma Knife is really showing a big impact.
Most of these centers are treating over 150-200 patients per year, enjoying very good financial stability, but also showcasing that if you want to do brain mets, the best way to do this is with a Gamma Knife. The uptake of Esprit shows that the future for the neuro business is very, very strong. On the right-hand side you have been asking when are we starting to see impact of ViewRay getting out of the marketplace? We have to admit that it took a little while for customers to realize that ViewRay is not really coming back. Now we are starting to talk with customers and they are really looking for solutions to commit to an MR-Linac program, but to make sure that they have obviously the best MR-Linac in the industry, which is the Unity.
The strongest example we have is that Moffitt Cancer Center in Tampa is this month deinstalling their Vray unit and starting to install the Unity and they expect to be up and running by the end of the year. This is the first example of a customer that is switching their Vray system to Unity. We have a very strong pipeline with other Vray customers to do the same. To show the impact of Evo in region Americas, we also see strong uptake in Latin America and we are really proud to celebrate our second Evo in Argentina. You see a picture here of the pediatric hospital Garrahan who will be going live after the summer. This is a strong testament that also in our developing market of Latin America, adaptive therapy is a key interest.
Our strength on the left hand side, on the bottom is our software offering. We have the best cloud solution in the industry, and especially customers that are suffering from cyber attacks coming to us really for help to get them back up and running with a lot of good expertise, but also to then have the conversation about how to transfer to cloud. The combination with SaaS orders, like to be said, is really helping us with the profitability and increasing in this case the margins for the region as a whole. The software business is very healthy, driven by the fact that we've invested heavily in a very strong cloud architecture in collaboration with our partner Microsoft and making sure that we expand the solutions in that software stack. We see a very strong uptake of SaaS orders.
Over 30%-35% is now SaaS based in the U.S.A., which is also giving a very stable revenue profile. Next slide. Now, how do we prepare for this launch? Because what we saw in Europe is that our key collaborators there are paving the way, and we're starting to see fantastic results coming out of Europe where they can do an adaptive treatment in under 15 minutes. This is an amazing speed, and it's also necessary because you want to make sure that you don't have to schedule extra patient slots in order to provide this kind of treatment. What we are doing here in the U.S. is that we are working with some key collaborators to start paving the way for the future.
As you can see on this list, we have some very prominent names like Sunnybrook, UT Southwestern, Medical College of Wisconsin, MD Anderson, Sloan Kettering, Princess Margaret, and so on. What these customers do with us is that they are basically providing the solution so that we can build the workflow that people will need to adopt in order to go to adaptive therapy. These key opinion leaders share their knowledge, they share their wisdom about how to set up the centers. We put this into a consortium approach just like you saw from our MR-Linac consortium. We have now included also the CT side of the business, and this is where we learn from each other.
If customers want to adopt to this new way of working, they tap into the knowledge of these key partners that we have developed, and they can go up and running really, really fast. We have implemented this solution in our link in our Atlanta Experience Center where customers can come to see it, to get trained on it, and to get ready for this change in radiotherapy. It is driven by our strong software platform. Like I said, Elekta ONE Planning, the combination of AI contouring and a very fast dose engine that is GPU based is enabling us to really get these speeds that I just described. With the launch of Adaptive Linac, we are really positioned well to take care of this growth opportunity.
With the average age of 14 years of Linacs, this is going to really help us establish a leadership position on hyperfractionation and adaptive therapy. Next slide. Now one thing that has been hampering the U.S. market a lot is that also the reimbursement system is not the same as for instance in the Netherlands where per fraction is currently the standard in the U.S.A., meaning that you get paid for every fraction you deliver. You can imagine that if you're in a community-based hospital and you get radiation for prostate, that they're not focused on doing this in five fractions. They want to make sure that they get financially paid. They are going to deliver 30-35 fractions. Like I said earlier, the impact this has on the family to go to the hospital 30x-35 x is tremendous.
We are working closely with some key thought leaders on how we can change this. Driven by ASTRO, we are now launching a change in the reimbursement schemes for the U.S.A. This is called Radiation Oncology Case Rate or ROCR. Over the last three months, the support that we've seen across the U.S.A. for this new legislation that's going to help us with reimbursement based on a bundled payment system is growing rapidly. We are now over 122 institutions in the U.S. that support this legislation. It's bipartisan, supported by Democrats and Republicans, and we believe that with the CBO scoring that's going to be done in the next two months, that we will have a very strong case to change the reimbursement cycle for the U.S.A. for radiation therapy.
Now you can imagine that if you get a bundled payment for radiation, you want to focus on hyperfractionation, you want to focus on adaptive therapy and this is going to drive replacement of those older machines as proof that we are the leaders in this space. On the right hand side you see the new picture of the Fort Worth campus of UT Southwest. UT Southwest is the leader in SBRT and the leader in adaptive therapy. They've selected exclusively Elekta for this new campus to equip this center with MR-Linac, with CT-Linac and also with brachytherapy to provide the best standard in care for adaptive in the future.
This gives us a very strong starting point to start working with administrators to do the business case about why it makes sense to upgrade their Linac right now and go towards the new platforms that Elekta is launching. We are really anticipating a fantastic summer coming ahead of us. Next slide. The key takeaways about our strategy in the Americas, we are going to keep focused on driving high margin product performance. As you have seen with market leading products in Brachy and in Neuro, we are going to accelerate our software growth driven by Elekta ONE, which is the gold standard now for adaptive therapy planning, but also where we can incorporate the broad Elekta portfolio evident by also incorporating Brachy and later on Neuro. We are the hyperfractionation leader in the market.
Globally we are seen as the leaders of adaptive therapy and we're going to drive this strategy into the U.S. where this reimbursement climate is going to help us change and we believe that we're going to be in a much stronger position heading in the future. Thank you for your time. I hand it back over to Christopher and I look forward to the Q & A session. Thank you so much.
Hello everybody. Good day. My name is Christopher Busch. It's my first Elekta Investor Update day, so I'm quite excited. I've been with Elekta since September 2023 and I joined as the head of research and engineering for the Linac and software solutions business. So I'm pretty much involved in what's going, coming out right now on the market. Since May 1st this year, I have been appointed to lead the business of Linac and Software Solutions. I'm in a rather new position and this position of course has the responsibility to create and maintain and refresh the portfolio that our colleagues have talked so enthusiastically about so that we create that and Habib and Ardie and others can bring it to the customers in the markets.
I want to give you a little bit of an update about what is the portfolio strategy that we are currently doing and why the topics of personalization and productivity are going to be key parameters that we work on right now when we talk about portfolio strategy. I also want to focus on the short to midterm. I could of course talk enthusiastically about the vision about where do we want to go with ablative radiosurgery in the body, where we want to go with biologically driven radiotherapy, where we want to go with combination therapy like theranostics. These are all great topics. What I really want to focus on is what's out now, what will happen in the next 12-18 months.
I will be a little bit focused on certain aspects of our portfolio and the logic behind it and why we believe it's not only sustainable, but also scalable. This graph you will probably see in many publications about current state of health care in the future, and this one is specific for cancer care. The truth is that the cancer burden that we are experiencing both in emerging markets and in mature markets is increasing. As was mentioned before, cancer is becoming increasingly in mature markets, at least a chronic disease that comes back. You have to treat and retreat and you have to think about what have you done 10 years ago, five years ago to be able to make the treatment forward.
Looking at the same time, also the complexity of treatment options is becoming greater, which is good because it also improves the outcomes, but it makes the workload harder. At the same time, the growth of skilled professionals who can actually do the work is increasing at a much slower pace. If you look at the timeline, this is like a 10 year outlook. You could probably extrapolate it beyond that. This is just getting more problematic and more of a challenge. What patients and clinicians need are better outcomes. A better outcome can be that a patient is treated at all with a good treatment, or that the patient retrieves into the recurring cancer of a low toxicity second or third treatment in the course of five to 10 years. That needs more personalization. What is the patient's outcome so far?
What is the outlook? What is the best treatment for this specific person? At the same time, to address the shortage in trained professionals, we also need solutions to give clinics how do they can use the resources they have with a higher efficiency. Getting more patients in the clinic with the same installed base and maybe in smaller increasing installed base of treatment machines, but also people who can utilize these treatment machines. Therefore you need more productivity. These things, as I will show in a few next few slides, can be quite antagonistic. You have to make a choice.
Do you go for utmost personalization, highest treatment complexity, best treatment, but also very time consuming, or do we say we go and optimize for throughput, but then maybe the treatment quality goes down because it's just impossible to put this for all the patients into the normal timeline. We believe within Elekta that we have a good portfolio and an optimized portfolio to help clinicians and clinics manage this kind of tension between these two things. If you look at the standard workflow of an image guided radiation therapy, which is more or less the standard right now, you see that you start with a simulation, so basically taking an image, high quality image, with a CT or with an MR. After that you do the contouring, segmentation, and then you do make a treatment plan.
You move over to the imaging and the treatment delivery at the device. Then you have, in this case, it's like 20x or 30x or 35 x the kind of loop that you have between treating patient comes back the next day, comes back the next day. Always you have to put, of course, what you have done into the oncology information system. What do you want to do as a clinician? You want to get a higher dose on the target, on the tumor as much as possible, while keeping the dose, the toxicity to the organs at risk, as low as possible.
You need to know exactly what's happening and what you want to do, ideally at the moment of treatment, at the day of the treatment, but not really what you did, what you measured three weeks before the treatment even started. That will result in fewer fractions per treatment. Going from 35, maybe to 5, maybe to 10, depends on the organs, depends on this type of cancer and the profile of the patient. We also want to get this not at the expense of very long treatment sessions. We want to make sure that when you do this, you can still perform a treatment in 25, 20, 15 minutes, as was alluded to by Ardie. We have more complex plans, we need to do more of them. At the same time, we have less time per plan. That is the dilemma.
What is our proposal? Cancer therapy. We want to bring it from up there, the conventional ones. You see these different boxes or the kind of arrows indicate the planning phase, the delivery phase, the individual treatments five times one week. Then looking maybe at what is the revenue and the outcome, go back for another week, another week, and these are three weeks up there, but you continue up to eight weeks. If you go into the classical hypofractionated treatment that is being applied today mostly at academic institutions of our leading hospitals, they say, okay, we go down to maybe five fractions, but you see that the individual delivery becomes longer, becomes more complex. Yes, overall this is a net efficiency gain. For every treatment every day, the number of patients per day will go down.
Even though in the end, of course, it's not so important for a clinic how many patients you have per day, but how many patients can you treat per year per Linac, per clinician? It's still something. Yet you don't want to have the patients wait until they get their treatment. It's still important to have a high number of patients per day. What we are looking at with Elekta is to say actually when you really look at integration of software and devices in a very strict, but also regulatory and safety quality assured way, you can actually make the penalty of having these more complex plans and having these more complex evaluation, segmentation, all these treatment steps that you need to do actually become so much that it more or less becomes as small, as efficient as a normal treatment would be.
You can still do hypofractionation, but for that you need deep integration. This is not something, I'll come back to that, that you do with a software package. You can do a lot of personalization with this, but productivity will suffer. That is the reason why we say we enable hypofractionation, but with limited to no part-time penalty during or between adaptive treatments and with quality assurance, a very important topic also for the regulatory bodies. Coming back, we have this portfolio of treatment devices, essential, and the software, and we believe for optimization of hypofractionation and all these online adaptive things, you really need to bring them very close together to achieve both personalization and productivity. If you have only part of this, it is becoming much more difficult.
Let's say it's very, very, very ambitious to try then to still optimize both for personalization and for productivity. We have talked, Tobias has talked a lot about the investments we have done in R&D. Please, this is a very wordy slide. Do not look, do not try even to read all the bullet points. The points that we are making here are that if you look at the last two years of ASTRO, the main conferences that people go to to see what is actually released, what is happening, you see that we released not only devices, CT-Linac, Evo, also software in devices, Unity with comprehensive motion management, but increasingly also many of these incremental updates and upgrades that either increase computational speed, GPU-based treatment planning, or do personalized workflows with things like Smart Flow.
The message here is we are seeing these things now in the market. These are usually asset-light upgrades. With asset-light, it means if somebody has a Linac there, with an incremental investment that can be an order or two orders of magnitude smaller than a new Linac, they can get significant upgrade in the functionality. It is similar to what happened in the car industry maybe 10-15 years ago when you bought a car there. After five years of driving, it was more or less the same car. Here we say once you buy the car, you will get the ability every year to get the car improved. Higher safety, more autonomy, all kinds of things.
This is both a statement of we have a lot that we have delivered already, but also you see a kind of a crescendo in the funnel that we believe we have a lot of things that are coming out and will continue to come out. A proof point of this are these two releases that we have been doing in the last year or so. One Elekta ONE Planning was talked about, the evolution of our Monaco treatment to some more comprehensive suite, and Elekta Online, which is more the adaptive part. You see here that we have rolled them out or are rolling them out.
You see that combination of more than 90 orders at a very significantly improved price point because the customers see the value. They see when they make the business case for themselves that this helps if they have a 10 times increase in speed of the computation, that this will reduce overall the time they need to do so. For them it's a good investment with return on investment. On the right, first of all, it's global as well, and it will continue to roll out. On the right you see some of the statements that customers are making that basically confirm that we have in the first one very clearly efficiency that's going up 30%, more volume at the same numbers of dosimetrists.
Second one, treatment total planning time per half, meaning that the wait for the patient between doing the simulation and the planning and starting the treatment becomes smaller. That's huge. The third one is really saying it's more technical. We see that the GPU acceleration is truly a huge step forward. That is actually a very important point that if you look at personalization, I think the left side is pretty self-explanatory. Tumors are dynamic. You are diagnosed, you make the therapy decision, you get the simulation, you start the treatment. The time in between them, the tumor will change and the longer you wait and for some aggressive tumors this can be a significant change. The second one, obviously once you start treating, over the course of the treatment, the tumor will shrink and will change.
The last one of course is that also specifically if you look at the middle to lower body segments, the patient is breathing, the bowels are moving, the different filling of intestines and bladders and so forth, there is a lot of shape and motion that we need to compensate. There are three important technology breakthroughs that we highlight here. Number one, the big step forward in imaging for cone beam CT AI- enhanced, we call it Iris, huge step in image quality, something that we had with Unity, we now have on the CT side as well. A big step forward. I'll come back to Unity versus CT in a minute.
The second one that we have this breakthrough in speed for computation, factor of 10 makes a totally different paradigm possible that was not there in the past when you had to wait 25 minutes for one plan to be calculated. If you can do this now in two minutes, you can do this every day for every fraction. The last one, that we have increasingly complex workflows. Elekta ONE OAS is now also focusing on enabling those workflows in a safe navigational way so that we can actually have this complexity in the clinic with still the nurses and the doctors being confident that what is going to be planned is also being delivered on. Every one of these three individually is a huge step forward. Every one of these three in itself is something that is of high value for the customers.
If you combine them together and then you look at hyperfractionation, you see that actually the true power of one plus one plus one is significantly more than three, comes for by the combination of these. These are not arbitrarily combinable. They are. You always have interoperability, that's a given. If you really want to automate this, if you really want to get through this fast and efficient and still safe delivery, treatment and adaption, you need to integrate them. That goes beyond one, two or three of them individually. You have to take a holistic view. That's what we can provide. Coming back to the topic of image quality, on the left side, that's a picture that will be shown in one of the deep dives later today as well.
You see in the red circle, kind of the bladder of a patient and then you see the bone structures around it. You see because the electron density is different, a very sharp delineation. That improvement in this delineation helps to make this automated for autosegmentation, as was mentioned before. This is between different organs. There is an interfraction, inter organ kind of application. If you want to do looking at the right image, where it is more about rectal cancer. The rectum is a different beast because it is soft tissue embedded in soft tissue, filled with soft tissue. Then you have the tumor, which is also soft tissue. With cone beam CT, it is almost impossible by the nature of how cone beam CTs are being made or CTs are being made, to see those subtle differences. MR makes it possible.
You see for the right example, where you want to boost dose inside a tumor, inside a prostate, inside a rectum, for that it is essential to have soft tissue contrast, which Unity provides from very basic difference in how the image is acquired than from CT. For many of the other, if you say you want to have a whole bladder irradiation or whole prostate radiation, cone beam CT does a great job. You will have a balance between what is best for what kind of tumor. Different clinics, different clinicians, different countries will also probably have different opinions about this. This is a choice. We truly believe the future of imaging will be both CT and MR based, just as it happened in radiology. There is no competition. Of course you can say there are borderline cases, but in principle nobody is arguing MR.
Will be replaced by CT or CT will be replaced by MR. When you have the time to go to the deep dive, later on John will also talk about how actually the development and the adoption of MR and radiotherapy is, I would say, probably mirroring quite to a significant degree what happened in radiology. History repeats or rhymes. Productivity. I showed this picture in a similar form, slightly modified before, but then if you look at it, you had this kind of arrow going from the simulation to treatment planning to the imaging and treatment delivery and then the information system. Now if you do online adaptive, this whole treatment planning becomes part of this iteration loop and they are becoming very closely integrated as said before.
These three things, these three different modalities have to work very closely together again. Quality assurance, patient safety is paramount. Yet you see automation is key to make this efficient. Zero click auto contouring, automated secondary dose check, extremely important. Then you have the choice, online offline is there as an option. Depending on the patient, depending on the doctor, you can say I want to do this today or not. That gives a freedom of choice that just was not there in the past.
We believe that this is something that uniquely differentiates what we have because you can do this on a machine that can also do standard normal non-adaptive treatments and you decide on the day. You do not have to have a dedicated machine that only does online adaptive, but you also do not have a software that is standalone but does not really integrate into the control systems of the Linac where you really must make sure that the right things are happening in the right very way and with the quality assurance there as well. We believe our solutions with Elekta ONE as the kind of best-in-suite kind of approach. On one hand, it has the OIS linked to smart workflows. On the right, we have the planning, the analytics also there, the high speed. This will all lead to a reduction in burden for the specialists and simplification of workflow.
Also an increase in safety because the more complex you make workflows, the more error prone they are. This is also kind of a dilemma slide, right. If you look at how we look at the ecosystem for these solutions, if you start from the very right, if this ecosystem is extremely open and you just look at DICOM standards, FHIR, HL7 kind of interoperability, you can basically combine many, many things from different vendors, self-made, self-written software together into one way to treat a certain patient. This is what many academic institutes are doing, this is what many leading clinics are doing to explore what's possible, what are options, and they want to have total freedom and that's totally the right thing for them to do. They pay the price of productivity for that.
For when you are in the research stage, productivity is something you optimize later. First you want to show that the treatment is really better. If you go to the very left, it is very closed. That means often that you say the treatment choices, the options that one vendor can offer or that maybe one device can offer, are limited. You have a very high productivity, but you trade in flexibility. What we try to do with intelligent operability is to balance these two things and to give clinicians the choice: do I want to optimize more for the right side? Do I want to optimize more for the left side? There we look at innovation, often led by Elekta, but then working together with best-in-class partners. MIM from GE was already mentioned as a key choice of a strategic partner.
The choice is how much do you want to optimize left or right? If you want to have a fully, highly productive, efficient, online adaptive workflow, you probably want to be more on the left. You can choose also not to do this. If you are in a research environment and you write your own segmentation AI enhanced tools, you can plug them in through standard interfaces. Again, you will lose productivity. These trade offs, we believe, are different for different institutions in different reimbursement situations. We want to keep these choices open for our customers. My key takeaways, hopefully for you, are that we have this dilemma between personal and productivity. We believe we have a way forward to do this. With Elekta, we believe we can go both for better outcomes and higher productivity.
The choice where you optimize is left to the customer. We have an integrated but also comprehensive portfolio. At the same time, our portfolio should not be limiting, but it will favor certain ways of working. With asset light innovation, many software driven, not all. We will go through installed base upgrades. Also, as mentioned before, SaaS business models make many of these innovation easier, affordable for our customer instead of having these big capitalized, this big CapEx kind of acquisitions that they need to make. Having said that, I want to hand over John Lapré. He is actually one of the guys who has been visions about this personalization productivity for a long time and he is leading our Brachy and Neuro business. John, up to you.
Thanks Christopher for the introduction. I hope to be able to radiate a little bit of the enthusiasm that I have for these businesses. Been 16 years in Brachy, 13 years in Elekta. I've been CTO for a couple of years and since a couple of years responsible for Brachy and Neuro businesses. More importantly, it's not about my enthusiasm, it's about our customers' enthusiasm for these businesses. We have huge market shares as was discussed. If you look at intracranial radiosurgery, the Gamma Knife is the golden standard. I will come to that as well for brachy afterloading-based brachy. We are by far the market leader as well in that space. Being a market leader brings also some kind of extras that you need to do. We have a very loyal and active customer base, the Brachy Academy.
We support it as a peer to peer training platform across the world. It's even been cited in scientific journals now with publications as the way of doing peer to peer training. Leksell Gamma Knife Society coming up in September. Started in 1989. Already a huge interaction platform. Neurosurgeons, radiation oncologists, around the Gamma Knife and what can you do? How can you exchange information? Not only that. It's a loyal customer base where these customers also pay well for our solutions. Why I come back to that. We are brachy and neuro combined, about 20% of the revenue. Very highly accretive to the EBIT contribution of Elekta. Now why are those customers so enthusiastic? Why are they saying we need to have the Gamma Knife, we need to do brachy.
There's a huge clinical evidence out there with very important data on patient impact, quality of life, effectiveness, both for neuroradiosurgery and that's mainly the Gamma Knife. And for brachytherapy on the left side you already can see that three more publications than all other technologies around. Intracranial radiosurgery, a fast treatment for multiple brain mets. It's not about one met. We see more and more brain mets coming with better diagnosis, longer survival of cancer patients. And this is the machine to really have more than one brain met effectively done in one fraction. I'll come back to that. Also very clear that if you do whole brain radiotherapy, you take margin, you take quite some margin, you irradiate healthy tissue.
The Gamma Knife has the lowest margin in all the machines that we have to exactly do the tumor and precise localization of the radiation. That brings another potential benefit that when there is a recurrence, you can use again an irradiation because you didn't touch the healthy tissues. Brachytherapy also, a lot of information, and I should say about these studies, it's not. We're spending clinical studies like iFarma. These are studies initiated by our customers. These are studies that are done by our customers in brachytherapy, very important in cervical cancer. Arti also mentioned that as a boost with external beam. What you see in this graph is if you only do external beam, it's just a light blue one, no brachy, you have a certain survival, five years survival. Now you add a very rudimentary brachy, 2D brachy, we call it. You see an increase.
The recent studies, the EMBRACE studies. One was retrospective. Looking back, the last one is really almost the golden standard of how you'd like to see some of these clinical trials. It's a multicenter trial, it's prospective, it's looking forward with a standardized protocol. You see what it does versus now brachy on the overall survival, 25% + 10% additional gain. Now what that had was an MR s tep.
Using an MR, when the applicator is brought in, that means your applicator needs to be MR safe. We have the widest portfolio of MR safe products and consumables. There you see one. I will not disclose prices, but do not think that this is a couple of euros. This is a very profitable part for our business, including consumables, including recurrence. Neuroradiosurgery with the Gamma Knife and brachytherapy really contribute to patient survival and quality of life. Not only our opinion. That is why our customers are so loyal and use this. What are those products? Caroline Leksell Cooke is sitting over there. We will show you the Esprit later on the Leksell Gamma Knife, as you can see here. It is not enough. We need to do treatment planning as well, like Christopher also said. Then we have basically the Leksell Vantage system and the arcs.
Now the Leksell Gamma Knife was of course the onset of Elekta. This is how Elekta started. Having it still, there is so much kind of testimony of what this equipment is able to do. It is one fraction as I said. Further hyperfractionation, you cannot do half a fraction. Further hypofractionation is of course not possible. There are a lot of potentially intracranial indications where you can use it. Now if you then look at Esprit and you will see more of that. There is an imaging component there because if you give one fraction, you need to know that you give it at the right spot. The same was done for brachy where we have introduced the imaging ring because for brachy otherwise you get an applicator. You have to be transported through the hospital to a CT or an MR.
With this applicator, which moves, etc. This Elekta Studio allows you to do it in room. In the treatment room, you can do it in principle as many times as you like. Make it adaptive, say hey, the bladder is filling or whatever. I need to adapt my plan and have a better personalization based on that one in room. Image guided and adaptive hypofractionation as well. Brachy is two to four fractions. Again, knowing where you give the radiation is important. Now, Christopher also already said that there is a kind of penalty when you do these kind of adaptive things. It's the same a bit in Neuro and in Brachy. The workflow improvement is so software dependent. We need to make sure that we can plan as quickly as possible. One of the previous ones that you saw was software including Lightning for the Gamma Knife.
That basically saves more than 50% of the time for planning. There's a customer quote who also says this saves so much time, it's so fast. It gives us so much time back for the neurosurgeon and that's important for Brachy. We do it with Elekta ONE Planning, much more integrated as well. Now if you then look at, all right, John, great, we heard about 2,000 Brachy, about 350 Gamma Knives. Here you see the potential for upselling and for upgrading. Still a huge installed base in Neuro of Perfection and Icon that we push to Esprit, including the software that we are developing. The same for Brachy, where the MicroSelectron to Flexitron will be pushed as much as we can to upgrade as well, with the Elekta ONE Brachy Planning around that. That's not enough. That's basically from our installed base.
We want to grow further into growth markets as well. That means some clinical indication expansions we're going to look at. We're looking at other business models. I already talked about the applicators. Very, very profitable. The subscription model is to make the total cost of ownership more insightful for our customers. Every three years these applicators have to be replaced and having a subscription model with Brachy as a service, if you will, is another push that we're doing. I want to briefly go to cervical cancer because I can hear sometimes people thinking cervical cancer. We have HPV right at this moment. As we speak, 600 females per day are dying of cervical cancer. It's not about toxicity. This is dying and that means there's still a lot of work and it's not evenly distributed over the globe either.
In the growth markets you see much more of these than in the more mature markets. We feel that also with new business models in those markets we should be able to tap into this big need. The WHO has declared a war on cervical cancer and we're working with the Elekta Foundation, IAEA et cetera to ensure that we can help here out. Expand clinically and grow the installed base by also some benign indications for neuro. It's not only about cancer. We're looking into neurological functional disorders, but it's not an easy one to get a lot of approvals for, but we do it. Parkinson's is one, but maybe OCDs for prostate cancer also there. It was already mentioned a boost of brachy to help hypofractionation on the Linac is another one that we're really looking at.
Again, rectal cancer was mentioned by Christopher as well. The combination potentially for rectal cancer, but where it all comes back to is we need to shorten the treatment times and we do that by software Selector 1 and Lightning. We are able to have very productive workflows and very much personalized. The key takeaways, as you can see, these are high performing and solid business lines. We are always saying these are indispensable parts of radiotherapy and indispensable parts of Elekta. Highly margin accretive. We have the market leading positions that we really should thrive on. As Ardie also said, the reason that these are high margin and loyal customers is we have superior clinical outcomes and the sustainable growth paths are around installed base but also around new clinical indications as well. A lot of it will be around software and workflows. With that I thank you for your attention. I give it to Peter.
Yeah, great. We will do a quick thank you. We will prepare ourselves for a Q & A and Emily here will move some of the tables and you also have clearly here in the audience the possibility to ask questions online. You can also ask questions live and you can also post questions on the chat. You have those possibilities. I will try to alternate the questions here between online as well as in the audience. By that I would like to invite the speakers back to the stage. Please join me here. Yes, I will move here and even though we're running a little bit late, I will keep the Q & A as thorough as possible. I think Emily, are you going to run around with my own Monica school doing that?
Maybe we start with Ste n in the back there, please. Ste n, you can ask the first question.
Thank you. Sten Gustafsson from ABG Sundal Collier, first q uestion to Tobias you talked about simplified and a ccelerated order to cash. What exactly does that mean? What are you going to do different this time?
Yeah, thank you for that question, Ste n. What we really are doing, please fill in here, Habib, is that we're really comprehensive now going through all the steps to make sure that we have a fully-fledged execution across. It is really a seamless process and optimize the various steps. It will enhance the quality of the process, it will enhance the effectiveness and it also will bring down hours spent in the process as well. It would lead to better quality, it will lead to lower cost. It is really a comprehensive approach really from when the order is taking on until we have collected the cash.
It is actually several steps and it is also I think here in the work to create a very predictable stable revenue stream. This is a key element to be really on top of the execution of our orders. Maybe want to fill in.
It's a comprehensive approach where once we take the order, we understand the customer and the contractual delivery date. When we know the customer delivery dates, we can align all the processes going from preparing the goods to booking for the shipment to the preparation of the installation in its phases. All this is about continuous monitoring of our backlog that I talk about, where we have a good visibility and predictability about the backlog to align all the processes together that from the time you take the order, we know when we're going to deliver, when the customer is going to be ready and when going to deliver and where we're going to recognize revenue and get the cash. It's all about predictability.
All right, thank you. If I may just quick follow- up.
Or not follow- up.
Then a different question. Jonas, you said you were quite bullish a bout the full year.
Could you elaborate a little bit, give us some colors? Is that growth or margins?
I think as we said during the morning call, the guidance or the outlook still stands there, but we're feeling quite good about that.
Right, thank you.
Maybe to add a little bit on that question as well. I mean here what you saw in Q4 and we have talked about it throughout the day here, we were able to strongly improve the gross margin. We are at the beginning of the launch phase. You should really build on that and utilize here the enhanced value that we can provide to our customers. It will be a continued hard work. You have seen the guidance and I think how you should look upon this is that yes, we have the guidance of increasing the revenues here in the fiscal year that we're in. It is also an important step here towards the mid term targets of reaching an operating margin north of 14% and a gross margin here to establish ourselves above 40%.
Thanks, Ste n. I think Christopher had a question. We'll move there and then we'll move further down the room later on. So Christopher.
Yeah, thank you.
The order cancellations, will that have any impact on sales? It also seems this increased focus on m argins you have, do you think that?
Will impact your ability to get back t o growing sales in live in market.
Or even above market, which was the ambition a few years ago? Thank you.
I can maybe start. You can fill in here, Habib. No, it does not change the revenue outlook. This is actually enhancing the quality of the backlog and actually removing non-accretive orders, so we stay firm on the path that we are on and build on the strong outcome here in Q4. That is work that is about to continue. No, it is not about adjusting any revenue outlook based on this at all as well.
It's the opposite because as you saw, we have 82% of the backlog still active. What we look at is the old orders that have not moved. We have been taken when the currency was at a different level than now and the cost of goods at different levels. It is boosting more the vitality, I would say, of the backlog and making it predictable and accretive.
Great. Let's move to the London table. We could call it here where we can start with Veronika. So please.
Excellent, thank you. Veronika Dubajova from Citi. Three questions for me please.
One, just to follow- up on the.
Order cancellation, do you expect it to have any impact on, on how customers.
Perceive you and whether they want to d o business with you?
Obviously if you've shown up and canceled a n order they placed a couple years ago. I t might have some repercussions.
Maybe a bigger picture.
Question on the commercial strategy.
In developed markets you have historically been very successful in tenders where I think your big competitor was maybe not as willing to be price competitive. Is what you're telling us today a c lear sign of that change in that strategy?
How should we think about your.
Ability to win in those tenders, which.
Have been an important driver of growth for you.
Maybe if I can squeeze.
In my third one just on the.
U.S. reimbursement changes, obviously there's kind of two very clear paths. Either we end up with big cuts.
Heading for 202 6 or, or 1031 or whatever the bill number is, passes.
Just curious about how you think about.
The market outlook under the scenario that.
ASTRO is not successful.
We do end up with much.
More draconian cuts to reimbursement. Thank you.
Habib, you start with two questions and then we move to Ardie for the third one.
Sure. Veronika, we act in the frame of the contractual agreement with the customers. Either we have a consent from the customer because it went beyond the three years of installation, or we have a consent with it. We act in that frame. Second point, from our competitiveness in the public tenders, not more about price. Now we see even in the public tenders, customers more want to continue in their installed base. They want upgradability, they want to go to hypofractionation and to go to, yeah, to adaptive in some cases. We fill all the cases, all the.
We.
Take all the criteria for that, not only on price. The third one, I think, question is for R&D for you, for us about reimbursement.
Yeah. Thank you for the question. While this situation is obviously a little bit fluid, we're working really closely with ASTRO and also ACR. The draconian measure you mentioned was really related to bundling radiology and radiation oncology. The feedback we're getting from the bodies is that they are trying to dissolve this because this is a mistake. The fact that there is now a groundswell from 122 institutions that are signing up for ROCR and also getting good support at the Hill from both parties, we feel strongly that the ROCR legislation is going to get passed. Now we will have to obviously see how this is planning out this year and when the bill is going to be taken up. If it goes into the draconian direction, obviously we have to regroup.
We are focused on making sure we protect the reimbursement rates for radiation oncology. We believe that cancer care is a very vital piece of healthcare in the U.S. and therefore we strongly support ASTRO in this endeavor.
Thanks. I think we have. David, you had a question. And then Robert, you.
Hi, David Ellington from JP Morgan. I'm afraid coming back to the cancelled orders, I just wondered what you expected, on balance, customers to do there. Do you expect them to come back and make new orders at a higher price or they just disappear and then related.
To that, typically I think you take.
A deposit on an order.
I just wonder if there are any.
Cash flow implications of the cancelled orders. We really have to pay deposits back and if not, does that mean you get to recognize some revenue?
Thanks.
Shall I start with the second question? No, there are no deposits here. That is the answer. It will not have a cash flow impact on these orders?
No.
As I said, we act in the frame of the contractual. The customers first, everybody understands that after three years, I mean the macroeconomic change, the cost of goods change, everybody feels the inflation, felt the inflation. They are not surprised on this. I repeat again, we act in the frame of the contractual agreement where we know that we have the right to change or to cancel based on the contractual clauses that we have in our contracts.
To clarify that a bit, David, the customers may come back and order again or they may not.
Here we'll go to Robert in the front here.
Thank you. It's Robert Davies from Morgan Stanley. I had three questions. First one was also on just the order cancellations. Just be curious when you look through the profile of the orders that you haven't taken out of the backlog. I think you mentioned a number of 82% of the backlog was still quote unquote active. What's involved with the remaining sort of 18%? Is that stuff that hasn't been cancelled, you can't cancel? It's within that sort of three to five year window? Just that was the first question. The second one was just I think you put up a slide showing the contribution of software around 21% of sales that have been relatively flat over the last few years.
Given that's been such a big focus for the company, perhaps you could give us a little more color of how you're expecting to accelerate growth in the software element specifically and then sort of tied to that, the software as a service bit of your business.
Just if you could provide us a.
Bit more color in terms of what that contribution is now, where you expect it to be in three to five years. Is there anything you can give us on growth, on margins around that pit specifically? Thank you.
Maybe Habib, you can start with the first one, the five years.
Yes. You rightly noticed that there is still 18% of the backlog and some orders to be materialized take more than three years. This is why, either, I mean, we understand that these orders will still move because the customer has financing and has a delay in the realization and the price and the margin is good, or some others are still on hold under investigation to decide about the status, either cancellation or keep them. The bottom line is that 82% is still active and transferable.
You can continue with the software questions.
Sorry, software question. Yes. It has been a relatively stable development if you look over the last five years, which I was presenting here. However, what you see here in the last year is actually the pickup that we are 1% up as a group in total, while software is actually growing by 7%. There is a, and when you look at the share of sales here for software, it is also enhancing in the last fiscal year. When you look at the order development, we are running here with an order growth above 20%, and this is not something that randomly has happened.
It follows by very precise and conscious investments that we have done, ensuring that we have software installers, ensuring that it's fully integrated in the commercial offering, ensuring that I mean here a very long term work here in coming out here with Elekta ONE and what just Christopher presenting. I think actually when you look at it and saw here again I coming back to Q4 and the gross margin improvement we've had, it's not a coincidence. It's based on actually planned actions here both when it comes to price increases.
We talked about Elekta Evo, but it's also an acceleration of high margin businesses and what we have seen here and it's actually been also when you look at the software developments, it's actually the three last quarters which have been strong in terms of the revenue growth and that work to emphasize software and drive software growth that will continue.
Maybe add one more thing to that because I think you mentioned it in your slide as one of the kind of productivity points that we are pursuing, that we have a very active program now on increasing and simplifying the installability, the deployment of software, make that as easy and as smooth as possible. Where in the past you had to send a service engineer to a site who has to go into the department, maybe even into the bunker, and has to put out a CD ROM or something like that and has to install it. We are increasingly moving towards much more automated updatability. This will also in the future, and that is again a little bit forward looking, make the speed and increase the simplicity also for our customers to get software upgrades in an easy and non-disruptive way much more.
That is much more easy. That is also something we are and have been investing on. Specifically, when you talk about the complex software installations of our OIS, of our comprehensive motion management, which is usually a suite of software, these things are going to benefit very greatly from our efforts in R&D and investments to make these processes easier. Even though the clinical functionality will not change, just the upgradeability will become a major multiplier for our efforts.
In the coming years w hen we get Brachy on Elekta ONE, that adds another potential of 2,000 installed base for upselling and upgrading for Elekta ONE .
Yeah, point.
We move over Bo here in the front table. You'll get it here. Sorry.
Hi, Bo at Joe Farm here. I have a quick or a small question or big for the team Europe and a very big one for the U.S. I will start with the first question then on Europe. That is, so Evo.
I think back on VLOG calculation was.
That you had orders of above 25 in your fiscal third quarter. How many orders did you have in the fourth quarter?
How fast can the trajectory be?
Compared to the Versa HD launch in 2014? Fifteen.
Yeah, I can answer on that question. So what you actually saw both in Q3, we do not provide explicit volumes here by quarter, but what you could see was a strong traction and momentum both in Q3 and Q4 from Elekta Evo in Europe. That is something to build on. Also when we roll out the global launch year of Elekta Evo.
I think 60% o f our Linac is now Evo.
Second half.
Yeah.
As we go forward, we think that the Evo would be on this segment. More than 50% of the orders of Linac could be an Evo.
It was 50% in Q3.
Much higher than in Q4.
If it's 60% in H2.
I think it's. When we talked in Q3, then we talked about the sort of say total orders. I think that the key here, what you see in both Q3 and Q4 is that we have a strong traction which we need to build on. It is a global launch. That means that everything will not be a straight line, but it's actually to build here and drive the momentum ahead of us. So far it has went very well. I think we are equipped here with a great product that we will continue to utilize not only in Europe, but also on a global level. The traction in Europe is good. How big part was the Software upgrade in Q4 or second half. We have not shared explicit details here by quarter as well.
What you could see is clearly an order growth of software which was much larger than the average order growth in Elekta. That was very notable and that is also a consequence of what you just heard here, Christopher presenting, and what you will also hear more from Anish, which I really recommend listening to later on.
You're already a much more difficult question.
I guess you are new in.
Your role and been successful in Europe and could you talk about the U.S.
Before you arrived, what you have seen.
What do you expect to do going forward excluding the upcoming approval of Evo?
Yeah, so I think arriving in the United States and looking at from an outside in perspective, you see obviously this is the home market of Varian, so I think a strong install base there from our competitor and also a lot of, I would say, academic leadership there where you see that the comfort level with Varian solutions is a little bit higher than with Elekta. On the other hand, people do see that the radiotherapy market is changing and especially I think in the direction we're heading with our solutions to give a flexible offering on doing adaptive treatments I think really separates us from our competitor. They have basically focused on a strategy where they launched a product called Ethos, which is the machine you have to buy to do adaptive therapies. Whereas we as Elekta have chosen a different path.
Not only do we provide obviously an opportunity to go to adaptive treatments with Unity, but also in the future we can deliver this with the Linac and most importantly it's also upgradable. We have a big install base of Versas, as you know, which is a great potential for us to upgrade not only on Iris image quality but also in the future for adaptive treatments. I think we have a good starting point here to really start growing again in this marketplace, strengthened also by the fact that we see that now also with CMM rollout, key institutions like Memorial Sloan Kettering, NYU, and MD Anderson seeing uptake in throughput with the Unity and started to see that also there's more indications being treated with MR-Linac.
This brand image that we're creating around adaptive therapy really sets us up for growth and I'm really strengthened by the fact obviously that the reimbursement climate is under a big focus here to make sure that we also help our customers getting paid for these additional steps. It's going to be, I think, an exciting time for us here in the United States. Working with our customers, confirming that they want to have a strong competitor to Varian. The other thing we don't really know yet is the impact of Siemens Healthineers dropping the Varian name for January 1st. It has a very strong brand value in the U.S. market, as you know. We definitely want to stay close to our customers, making sure that we can benefit from that change.
Thanks.
Let's move back to Mattias in the back.
Thank you. I have three questions. I appreciate all of the discussion around margins and the path forward to make.
It more profitable growth, but what we're.
Lacking here a bit, I think, is.
Commentary on, you know, future growth ambitions from Elekta.
You clearly cover the efforts, of course, everything you're doing. How are you seeing market?
Growth going forward and what is reasonable.
For Elekta to achieve? Particularly perhaps interested in the U.S.? I mean given the sort of fading number of installations we've seen in recent decades and we saw in the presentation and of course a high density of Linacs as well, less fractionations should mean less need of Linacs, so maybe cover that. Also on the U.S. I think we've seen a decline in constant currencies over the past six to twelve months in service revenues. Just help me understand a little bit what is driving that development and when that could turn positive again. Lastly, so gross R&D moving towards 10% of sales. What is maintenance CapEx for Elekta and how is that expected to develop going forward? Those were my questions. Thank you very much.
Maybe you could start with the first question about growth and then Ardie can add on the U.S. side on that as well.
No, we see like the growth is different dynamic in different parts of the world and we see in China for example this year the orders coming back on the growth. We still have a growth opportunity Southeast Asia and other part of the world. We in the emerging market, the growth would come as well from more soil base where we do not have high soil base. And this is the expansion on our soil base with the adaptive radiotherapy so it can grow the market in some growing market but as well is growing with more competitiveness with the. With the new solutions that is coming. We see still a growth and replacement market in Europe, very active replacement market. It's not only about access, it's more about elevation of the care and having to higher techniques.
I would say before going to the U.S. it's not only about top line growth, it's more about accretive growth. I wanted to comment as well before about the solutions, I would say backlog. It's not only about having like MR-Linac, which might be less accretive than the software or the Brachy or the Neuro. It's managing and forecasting as well the profitability rather than the top line here. This is what we are about here.
Maybe, Ardie, you can add to the U.S. growth ambition there.
Yeah. Just to rephrase your question really, what's the impact here of going to hyperfractionation for the marketplace? Yes, the answer is that obviously if you can do hyperfractionation, you can treat more patients. I think for us at Elekta this is a very positive development because that means that the older equipment, as you saw in my slide, the average of 14 years, those are older linacs that basically just do the basics. If you want to go to advanced treatment techniques like VMAT and later on hyperfractionated adaptive therapy, those capabilities are not available in those centers. It is an opportunity for us to upgrade these machines to our technology. We believe that our offering in that area is stronger than from our competitor and therefore we believe that this change is going to be beneficial for our Linac growth.
It's obviously also clear that we have focused a lot on Unity developments. Now we start to see with the developments we have on the Linac and the software side we have a very good uptake and starting to turn this ship around. What you will see over the next couple of quarters is that we indeed are starting to increase again on the solutions revenue side. Then also on the service revenue s ide.
M aybe Ardie, you can add on the question around services development in U.S. as well on that question how you see it.
Yeah, so if you look at the services development where we have strong install base, we see that those services are actually increasing on the Linac side. I just described obviously that there was a little bit of a weakness that we are now addressing with this new portfolio coming out. Therefore I see that that sets us up for a future growth path with good profitability.
Thanks, Ardie. Maybe to be asked, there was a question about gross R&D and how big portion of that could be maintenance investment.
No, that is a number that we don't provide per se. What you can say is that the current R&D investments that we are on allows us to have a strong innovation pipeline and actually sizable investments for developing our products. That's how I would frame it maybe.
To add a little bit to that because when we talk about maintenance, it very much depends also about what product or part of the product portfolio we are talking about. We have some very modern, very recent releases that are fully on par with the tech stack and maintenance is there, but it is also already quite automated and modern in a web environment. Often, of course we have also a lot of history and there we need to do some active work right now, which we are doing, but also there. That is something again utilizing innovation not only for our products but also for the way we are working. We are active, very active right now in programs.
Also how to automate many of the more basic innovation topics that we need to do, like test automation, which can be a huge effort, but you can also automate that. We are using generative AI right now to automate or to generate our test cases that used to be done manually. I think also there you will see that our innovation capacity for the high value add topics will go up. Of course maintenance as a percentage of overall, let's say, effort will probably still be reasonably high. You see that the manual part of that will be decreased and we reallocate those highly valuable manual people in our R&D teams towards the value added topics.
There's maybe one thing I don't like, maintenance as well, but if you look at continuous engineering, yes, we have sometimes that we have obsolescence, we need new parts and that's immediately an opportunity for COGS reduction. It basically cuts through multiple things.
Thank you. One more question there.
Hi, thank you. This is Estelle Pang from Bernstein and I'm asking on behalf of Lisa Clive.
Just to quickly kind of understand.
A bit more of the canceled order in the backlog.
Is there any common theme behind those cancellations? Were there more from emerging markets or were there any like large tender based- contracts?
Thank you.
The common theme is that it's non-accretive orders, which actually here is where we see an opportunity to enhance the quality of the backlog. That is what we. Yes, there is a clear part which is from emerging markets as well.
Good. If no further questions in the audience. Yes, Robert, you could move there too. Let's start with Robert here, then we'll take Erik there as the next question.
Thank you. I just had one follow-up question around how you structure partnerships within your business, both on the hardware and software side. You're obviously kind of putting up a fully sort of integrated workflow solution. How often are you using partners? Where are you using them? How heavily are you leaning on partners, particularly on the software development side. I'd be quite interested in that. Thank you.
We are of course working with partners and some of them are exclusive, some of them are preferred, and some of them where we are agnostic and just basically provide the interoperability to be able to interact with an Elekta solution. When we talk about the strategic ones, we are and will be very selective because there we really need a long-term, multi-year commitment to have a co-development effort, and that includes not only the development effort on the engineering side but also a business case and a business model that is beneficial for both parties.
When we talk about having increased interoperability and then you can talk about partners where we have preferred partners but are not exclusive, there we will have open access to certain interfaces that are accessible for everybody, and we will have some selected kind of more proprietary protocols that we will open up also with new business model for partners that allow them to integrate deeper. We do not need to really do co-development for that. We can open them up, and then we have maybe a co-test and co-validation of the resulting workflows.
The last point, we as Elekta are committed to an open ecosystem, so we will continue to expand our interoperability, and that is not only with partners but also with parties like EMR providers that of course also have large IT infrastructure in the hospital that we need to be able to connect to, and they need to connect to be able to connect to us. Expect also there some developments in the future.
Thanks.
We will. Yeah, Christopher here. If you move to Christopher then we have Veronika, only have Erik. Sorry, sorry. Erik first.
Hi, Erik from Danske Bank. Y ou said in the introduction way.
Back that you're now only going to.
Take profitable orders, which sounds like a good starting point.
I would have thought that you've.
Always taken profitable orders, but then maybe over the past couple years maybe got.
Caught out first from supply chain and then inflation.
What's actually different with the way.
You take orders now? Do you have a larger margin of safety on margins?
Do you bake in classes?
Do you have additional protections in any way?
Do you want to speak about that or should I start a bit?
Sorry.
I think what we've done, and Habib talked about that, is we have really dug into the processes around our order to cash program and so on and have quite much stronger safety net also with the capabilities to adjust prices way much quicker than we have been able in the past. Maybe Habib.
Yeah, so actually when we look at the quote to order to revenue we reviewed our pricing model and in the pricing model we anticipated the standard costs that we can take into consideration in the beginning as a cost and as well what targeted market value we can have with the value that we are conveying to our customers. First, much more robust pricing model, embedding the standard cost in order not to have surprises like we got in 2021 where we had a surge in the COGS and surge in the logistics and so on. Now it is much more stable and very robust pricing model. Plus we compare ourselves to a target value which our customer is ready to pay for our solutions. Much more robust pricing model.
We have time for one more question. Did you have a follow- up or...
No, I want to ask something else.
Okay, one more, Erik. And then we have two.
Okay. I think software is probably going to be the most important part for the next ten years, maybe forever. But you have quite a different selling process compared to others. The way you sell software, especially to the U.S., I believe you're only going to sell it as a service, but no one else seems to be doing that.
When I buy something as a.
Service, I buy it because I want.
To be able to cancel it.
When someone buys a Linac, they know they're going to use it for 12-15 years and they're going to need software on it.
What's the rationale of even selling it as a service when customers have that?
Sort of approach to using it?
Maybe Tobias, you can start on that question and Christopher can add on that.
I think you can fill in here more from a sort of commercial and technological point of view. What we are aiming to do here is of course that you have a partnership with your customer over a long period of time and you work here with upsell and cross-sell opportunities where software as a service comes as a national ingredient to both work together with the customer. Also, for the customers it means that you have a lower CapEx at the beginning, you have a more smoother, you can also plan your operations than having spikes in investments when new innovation comes out. This actually allows the customers to have a more planned and also predictable cost for the software and also the usage of the software and the benefits from the software. So that I would say.
Maybe here, Christopher, you can add on from.
Sure. I mean number one, you mentioned the kind of the ease of cancellation. It's not a Netflix kind of subscription that you can cancel and you go to Disney+ or something like that. Once you are in an ecosystem of an oncology informatics system or have treatment planning software. These are usually very sticky for products and projects because they are closely related to how you train, educate your staff, how the whole workforce is being used to follow certain processes and everything. To shift from one software to another regardless of whether it's a SaaS model or not, is a huge major undertaking.
I mean that's something if you have seen what happened in the U.S. when they had to shift to the EMRs, those were multi-year, multi-billion dollar projects sometimes and this is a little bit easier but nonetheless it's a non-trivial thing regardless of SaaS or not. Secondly, SaaS provides the flexibility to be in an evergreen situation and saying you don't have to worry about having a capital budget for the next upgrade or install. You know you can get it and you know it's easy to install. The third point that increasingly will play a role here is the topic of cybersecurity. Right. SaaS models specifically when they're in the cloud are much easier to have certainty about having the latest updates also related to cybersecurity, which are different and also seen by the FDA different from clinical upgrades and updates.
The CIO, the Chief Information Officer in the hospital, will increasingly demand these kind of models for the departments to work. That's not just specific for an oncology department, but it's a hospital-wide decision. I believe that SaaS models, maybe not for all departmental isolated things, but for specific, form the backbone and the infrastructure for hospitals, will become increasingly dominant. I said the flexibility to cancel is there, but it's always and has always been a major undertaking that's not taken lightly.
Thanks. We have time for one more question. I guess maybe Rikard, you can take that and then we will move over to the concluding remarks from Jonas. So Rikard, you have the chance to, and you all have, who is going to stay here in this opportunity in the deep dives to ask questions as well?
Yes, Rika and Keanu Pande, just a.
Final product related question. Electa Planning Pro with the adaptive.
Functionality, is that still only for pelvic indications and has there been any expansion of indications?
What's the willingness for Versa HD customers?
To actually pay and sort of adapt.
This technology given the limitations there?
That is of course a statement. At this moment we have the CE clearance for the pelvic area. We are very close to release, not details further, to release the next body parts and then have a sequence of body parts so that we have a complete coverage of all the organs that are really needed. That is a commitment we already make to our customers and there is a committed roadmap for that. You will see that increasingly we will not only have also updates of these specific body part models, so pelvis 1.1, 1.3, because also there technology moves ahead. We will also start, next to the more body parts, releasing packages related to the imaging that are more related to motion management, to artifact reduction of gas bubbles, metal implants in the hip, in the face.
You will see that there is going to be a full roadmap of further things. This is not just a one-time release. You say you have three body parts, you are done. This is a full roadmap, both within the body parts because the technology will improve, but also going increasingly from static body part improvements to dynamic motion management. There we are benefiting very much from the learnings that we have from Unity and there is comprehensive motion management. Stay tuned. You will see in the not too far future that we will start to introduce motion management also for CT- Linacs. That will be a major new thing.
Great. Thank you all and thank you all for the questions here in the audience. We will have Juvena staying on the stage concluding this first part of the day for both the online as well as you here in the audience. I will be back and tell you a little bit what's going to happen later on.
Thank you, Peter. Thank you all for coming and attending, and I hope that you will join us later at Forskaren. It has been a real pleasure having you here, and it is my first investor update and very, very interesting, and thank you for all the interesting questions. I will not be lengthy. I just want to reiterate that this, you know, this is our short-term strategy that we are working on now, which we have seen during the fourth quarter has been very successful, driving the business with the focus that we have on profitability and margin and so on, and puts us in a different maturity level with that. I thank you all and see you later. Thank you.