Despite billions of petrodollars spent on healthcare in Saudi Arabia, the kingdom’s targets for healthcare service have not been met in recent years. With the government’s push to include more private investment in the field, and Saudi Arabia’s burgeoning demand for medical services in a country that has high rates of diabetes and other ‘lifestyle’ diseases, the kingdom may have the potential to offer the highest returns in the Gulf Cooperation Council to those who can build and operate cost-effective hospitals and medical networks. Thus, models are now emerging in this market — traditionally seen as almost impenetrable — that many are suggesting will offer substantial returns for investors without skimping on quality healthcare.
“Any successful [private healthcare] project which is looking to expand across the GCC should consider a joint venture approach with an experienced partner on the ground,” wrote Mohammed al-Qahtany, chief executive officer, Al Aman Investment of Kuwait, in a 2009 report by Ithmar Capital titled ‘Meeting the GCC Healthcare Challenge 2050’. “This ensures both local support and at the same time enables the project to benefit from the accumulated experience of the organization as a whole. Joint ventures have a successful track record, and this is the way to move forward.” It seems some major investors took notice.
The doctor strikes a deal
Dr. Sultan Bahabri founded and served as CEO of the 894-bed King Faisal Specialist Hospital in Riyadh; now as chairman of the Riyadh-based Ebram Investments, he has formed a joint venture with the new Beirut-based Rizk Red House Healthcare (RRHH) to develop a chain of 10 specialty hospitals throughout different cities in Saudi Arabia over the next eight to 10 years. The $1.35 billion project was announced in December 2011 after Red House chairman Mazen Beaini, and Bahabri, decided on a strategic vision that would require exceptional medical operating experience. Beaini then looked to Sami Rizk, the former general manager of Ashrafieh’s Rizk Hospital, as the man for the job, and RRHH was formed as a partnership. It is not hard to see why the trio has come together.
The Saudi government has long planned to transition healthcare from the public to private sector. However, it has been slow to do so and continues to buoy the majority of the industry, as most estimates put government expenditure at more than two-thirds of total healthcare spending. As part of a plan to increase the profile of healthcare in the country, the government announced that an extra-budgetary spending of $18 billion will be allocated to healthcare and social services under a five year plan, begun last May. As part of the initiative, 120 healthcare centers and hospitals will be built and four expanded.
To reach the target of 3.5 hospital beds per 1000 people by 2014, the kingdom will need to add more than 41,600 beds to its total of 55,000, as of last year. But so far the private sector has been hesitant to make bold moves, as the nature of the capital-intensive industry requires many years before significant returns are seen.
Bahabri points out that returns for healthcare providers are around 6 to 8 percent worldwide, “but in our region it is about 10 to 12 percent.” In the last three years, he says, some private groups have seen returns of 22 to 25 percent, mainly because governments started to buy those services, a trend that will likely continue. Globally, revenue streams are differentiated according to each medical specialty. For example, diagnostic centers tend to provide exceptionally high returns compared to other domains. “Some specialties make [profit] after three years of operation; [for] some it takes eight years to make money back,” says Rizk.
Saudi Arabia’s health ministry still owns and operates more than 60 percent of hospital beds in the kingdom, but even so, a recent report by management consultants Booz & Co noted that: “many private companies are either majority owned by the government or have government officials on their board in the GCC — private investors will be wary of going head-to-head with such companies.”
Another reason private sector investment has not surged is because regulation is nascent, with the government announcing in 2010 that it would set up an authority to track private facilities.
Lifting the lid
In March of 2011, King Abdullah issued a number of royal decrees to encourage foreign private investment in healthcare, in which the cap on loans to private hospitals rose from SR50 million ($13.3 million) to SR200 million ($53.3 million).
In fact, though both Ebram and Red House had been doing their own independent research on the Saudi healthcare market, it was not until King Abdullah’s initiatives were announced that the two got in touch. “As a Lebanese company headquartered in Beirut, we were motivated because of the foreign investment incentive,” said Beaini. “Now we have access to government authorities and groups like [Saudi] social security which has billions to invest.”
Mandatory healthcare insurance, which has been an obligation for the private sector since 2009, “will ultimately apply to all Saudi national employees as well,” according to a report on the Saudi healthcare industry by the National Commercial Bank, one of the country’s largest lenders. As of today, an estimated 20 to 30 percent of Saudis have voluntary health insurance according to Bahabri.
As such, the joint venture plans to construct hospitals in cities like Riyadh, Jeddah, Khobar and other areas outside major population centers. “Al Kharj, close to Riyadh, doesn’t even have one [civilian] hospital. All these areas already have infrastructure so we don’t need to build,” says Beaini, who insists that people should not have to come to Riyadh and Jeddah for quality care. Already, real estate consultants Colliers International have completed a feasibility study for the first hospital in Riyadh in November 2011 and will decide with Ebram what the specialty will be in each area where hospitals are planned.
Getting the money
The joint venture between Ebram and RRHH has adopted a fund-like procedure modeled on private equity but with the option to use other structures to raise 70 percent of the $1.35 billion cost not covered by government loans. Thirty percent of the $1.35 billion cost will be covered by soft loans that can be paid back with interest over 20 years, with a plan to go public down the line.
Till now, the joint venture has raised the seed capital, which covers 55 percent of required equity, and will officially launch a road show in the second quarter of this year to raise the rest of the money, mostly from international healthcare funds and operators. “We prefer institutional investors since we have worked with them before in our other projects,” says Bahabri, adding that they may approach investment banks as well. Funds will start to be deployed by the first half of this year.
So far, international healthcare operators have shown eagerness to invest, and cover the remaining equity in exchange for long-term (20 to 30 year) contracts as facility operators. “We have European, Canadian, Indian, all the big players in the healthcare sector,” says Beaini. “We have [even] been approached by Spanish contractors trying to get into partnership. If they have a proven track record in healthcare, this could be an added value for us.”
Since most Saudis who seek care abroad end up in Germany, Britain, Thailand and India, it would make sense that potential operators will be found there, according to Booz & Co. Treatment in oncology, neurology, orthopedics and cardiology centers are most sought by Saudi patients abroad, the firm adds.
Costs and returns
The time is ripe for such a healthcare venture in the KSA market, according to Bahabri, given the supply shortfall and the interest that will be drawn from the financial sector due to the innate financial setup. He says, “In KSA, we have a very healthy market for Initial Public Offerings (IPOs). We have [around] 20 health insurance companies listed and only one listed healthcare company on stock exchange [Al Mouwasat Medical Services], which is the opposite of the global reality,” where listed healthcare providers outnumber insurance companies. The planned IPO could pave the way for a more mature healthcare market. “The authorities are… encouraging us and other healthcare companies to go public because it’s low-risk and it suits pension funds and other funds that would like long-term sustainable income,” says Bahabri. The potential already exists due to rising rates of diseases like diabetes and the onset of an ageing population, as well as the penetration of supportive industries like health insurance.
While $300 million has been marked for land acquisition (locations of the first hospital will be chosen in the coming few months), about $1 billion will be spent on design and construction (each hospital may have up to four surrounding speciality centers); equipment will most likely be leased.
Since medical equipment and technology must be imported, traditionally it has been a tricky piece of the pie for new private players who seek to provide healthcare in the GCC. But Bahabri says he has a plan to bypass those expenses: “We are going to change the rules of the game in a very conservative industry. If we are not going to be innovative, we will not be in it. You don’t have to own your CT-scan anymore. You don’t even have to lease it. You can share revenue with the provider and that would improve your margins.”
By comparison, each 300-bed hospital will cost around SR500 million ($133.3 million) as compared to the $70 million cost of the 300-bed Jeddah East Hospital under construction, a project of the Saudi Ministry of Health. “In the United States $450,000 to $500,000 is the standard cost per bed when developing a hospital, including construction, equipment and land,” says Rizk. “We are spending $450,000 per bed [including construction, equipment and land] but we are financing it differently.”
Unlike other development schemes, when building hospitals it is crucial that the operator and contractor are in sync from the design phase so as to coordinate patient flow based on what kind of specialty the hospital will serve, according to Rizk.
Ebram Medical, which is legally designed as a public company, will have a board and audit committee, and will operate the hospitals but will form strategic alliances with international operators, hinting that Asian models from Thailand, Malaysia and India are preferred over Western operators due to cost-efficiency. “The challenge is not to build, it is how to operate… the investment part is easy, it is the operations and services that are hard,” says Bahabri.
Using a more sophisticated version of a cost-effective model already in place in the region, the group plans to bring in American doctors for 15 days every 3 months and schedule operations during the strategic interval. But costs will have to be kept close to the standards of the kingdom. “Today, open heart surgery in KSA is around 40,000 Saudi Riyals ($10,600) as opposed to $40,000 in [the] US,” cited Bahabri.
In 2010, KSA was already exhibiting higher prices in private hospitals as both the inpatient and outpatient visits are estimated to have increased by 5 percent and 8 percent that year, respectively, according to the National Commercial Bank’s report on Saudi Health Care published in July 2011.
Issues and concerns
“Our strategy is ‘what not to do,’” says Bahabri. Certainly, it is not to imitate models of medical pinnacles like the Mayo Clinic in Minnesota, but instead to focus on delivery of a specific area of medicine and only provide post-hospital care in later phases after secondary care is established. Hospitals would be run like a network with “specific disease-based centers” surrounding them, according to Bahabri, which will collaborate with other research centers.
“For each disease you need a hospital, which has been the trend in last 10 years, and each facility will have a different strategy,” he says.
In addition to high expectations from demanding healthcare recipients and the cost of importing medical equipment, Saudi Arabia faces a shortage of local talent in terms of medical staff and will need to attract foreigners to fill the gap.
Though more than 100 nationalities work as physicians in KSA, Saudi doctors are preferred, according to Bahabri, who also points out that Philipino nurses are on their radar, as they have a well-established and respected history in the kingdom. To integrate the pool of medical experts, the hospitals will have their own training programs. In parallel, the government is trying to increase the number of Saudi physicians. In December 2010, Saudi Arabia‘s Education Minister announced plans to build medical colleges and hospitals at all 24 government universities in the country.
There is competition from other well-established players that have expanded in recent years, like Magrabi Hospitals and Centers, and Saudi German Hospitals Group, though no new major players have emerged in last 10 years and Bahabri says the joint venture’s focus on disease-based centers will differentiate its market.
RRHH — a Lebanese company based in Beirut — aspires to distribute their know-how in management, operations, design and construction, with a focus on the GCC across the Middle East and North Africa.
Though there were 68 hospitals in the United Arab Emirates in January 2011, bed demand will more than double to about 165,000 and treatment demand will rise by 240 percent by 2015, according to a January 2011 report by the Italian Trade Commission. Healthcare costs in the Emirates could multiply by a factor of five to $60 billion. So far, however, billions of healthcare dollars are being spent outside the country, a major loss of revenue. The most recent figures from the Abu Dhabi Chamber of Commerce notes that UAE residents spent $2 billion on treatment abroad in 2009, though the government has a stated policy of encouraging private investment in order to supply its domestic medical needs.
Centers for diabetes are particularly in short supply, with the International Diabetes Foundation noting that the GCC spends $5.5 billion a year on prevention and treatment of diabetes, accounting for 14 percent of its total health expenditure.
Lebanese companies may reap great benefits due to their long history of accredited medical institutions relative to the GCC, says Rizk: “The GCC respects Lebanese know-how in healthcare, we are renowned for it.”
Citing the potential of healthcare tourism in Jordan and Tunisia, Rizk stresses that the strategy must be patient-centered in the new healthcare era, where the type of design prioritizes cost-efficiency. As for markets in short supply of modern medical services, RRHH aims to expand beyond the conservative model of sticking to construction, design, and equipment placement, with plans to develop a strong network of services, management, healthcare tourism, maintenance, facilities management, biomedical engineering and talent management.
“Our quality is because of the culture and this is what we will export,” says Rizk.