Presentación en el curso del 2º Health Open Day, Coimbra, 26 octubre, 2011

1. A presentação sobre o
mercado da saúde
Ignacio Riesgo
PwC Spain
www.pwc.com/es
2º Health Open Day
26 de Outubro de 2011

2. PwC 2
Table of contents
1. Healthcare systems megatrends
2. European healthcare public systems overview
3. Main issues of European private healthcare sector
4. New players: private equity companies
5. Challenges of European health systems
6. Main trends of healthcare systems in Europe

3. PwC 3
Healthcare systems megatrends
1

4. PwC 4
Ten major forces are driving change in the health sector
1. Healthcare is expected to be the sector with the highest growth in the future.
2. Changes in disease patterns and demography.
3. Great impact of new medical technologies.
4. Great impact of ICT.
5. Concerns about quality.
6. Appearance of the “new consumer“.
7. Revolution in the way of providing services.
8. Changes in the paradigm of the biomedical model.
9. The emerging “new health economy”.
10. A place for global players?

5. PwC 5
1. Healthcare is expected to be the sector with the highest growth in the future
Healthcare cost growth over GDP estimations
Source: WHO, PwC Analysis
20,6%
20,3%
20,0%
19,5%
19,1%
18,7%
18,3%
17,9%
17,5%
17,2%
16,6%
16,3%
16,0%
21,0%
14,5%
14,0%
13,5%
13,0%
12,5%
12,0%
11,5%
11,0%
10,5%
10,0%
9,5%
9,0%
16,0%
6%
8%
10%
12%
14%
16%
18%
20%
22%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
15,5%
15,0%16,9%
OECD w/o USUS

6. PwC 6
2. Changes in disease patterns and demography
• Ageing population.
• More chronic diseases burden.
• More mental diseases burden.
2000 2020
(projected)
0
80
120
160
40
Millions of American affected

7. PwC 7
3. Great impact of new medical technologies
Design drugs
Diagnostic imaging
Minimally invasive surgery
Test and genetic maps
Gene therapy
Vaccine
Artificial blood
Xenotransplantation
Manufactured by identifying the physical
structure and chemical composition of the
target and designing molecules that act on it.
Progress in all areas: energy source, technology
of detection, image analysis and visualization
technologies.
Advance in optical fiber technology,
miniaturization of instruments
and navigation systems at catheters.
The detection of genetic predisposition offers the
basis to begin preventive measures. The test has
been developed to detect almost 500 diseases.
The artificial introduction of genetic equipments to
replace defective or eliminated genes. There are over
2.000 patients at clinical trials worldwide.
This avoid the organ limitation and treat other
diseases such as diabetes and Parkinson.
Stem cells utilization
The magnitude and impact of the use of stem
cells will be huge in the coming years. The
first successful will come with skin and bones and
then with organs and tissues.
New uses of vaccines for non-infectious disease. It
´s expected a great potential to prevent cancers that
it´s related with virus.
The FDA has recently approved products
with synthetic hemoglobin, which can be
an ideal replacement for blood transfusions.

8. PwC 8
4. Great impact of ICT
Patient
Physician
Information and
clinical decisions
Medical
knowledge
Medical
History

9. PwC 9
5. Concern about quality
Number of deaths per year
Sources: National Vital Statistics Report, Institute of Medicine
Deaths from medical errors compared to other
common causes of death
Medical
errors
44.000-98.
000
Motor
vehicle
accidents
47.000
Breast
cancer
41.000
HIV
14.000

10. PwC 10
6. Appearance of the “new consumer”
We define new consumers as people who have al least two of the following three
characteristics:
• Discretionary household income of $53.000 or more (in constant 2998
dollars).
• At least 1 year of college education.
• Experience with information technology (e.g. owns a PC).
Description of new consumer attributes in 2005
Source: US Department of Labor.

11. PwC 11
7. Revolution in the way of providing services
Revolution in
care delivery
New drivers…
• Connectivity and new care/disease
management models
• Telemedicine
• Electronic Health Record (EHR) /
Personal Health Record (PHR)
• Health 2.0
• Disruptive innovation through new
entrants (ie: Google, Microsoft, etc.)

12. PwC 12
8. Changes in the paradigm of the biomedical model
Biomedical model Future
Episodic care Chronic disease management
Goal: recovery
Control and adaptation to the
disease, when recovery is not
possible
Fee for service Subscription
Process led by the supplier Process led by the consumer
Curative medicine Predictive medicine

13. PwC 13
9. The emerging “new health economy”
Cosmeceuticals
Foods and
supplements
Dietetic
treatments
Alternative
medicine
Functional foods
Well-being
Traditional
Healthcare

14. PwC 14
USA, Hong Kong, India, Malaysia,
Filipinas, Portugal
Sweden, Denmark, Finland, Norway,
France, Germany, UK, Spain
UK, Australia, Ireland, Saudi Arabia,
Spain, Thailand, Hong Kong
Germany, Belgium, Netherlands,
Luxemburg, Portugal, Czech Republic,
Norway, Sweden, Spain and China
10. A place for global payers?

15. PwC 15
European healthcare public systems
overview
2

16. PwC 16
Countries in Europe have tended to adopt versions of the three main models
of health care
• Tax-based systems in
western Europe.
• Social health
insurance countries
in western Europe.
• Central and Eastern
Europe.

17. PwC 17
The Bismark model prevails in Continental Europe

18. PwC 18
Main characteristics of the Bismark model
Contribution collector: Third-party payer
Population Providers
= sickness funds
bipartite self-government
Public-private mixMandatory insurance
Usually wage-related
contribution
Contracts
Limited
government
control
Free access
Choice of fund

19. PwC 19
The Beveridge model prevails in Britain, the nordic countries and some
southern European countries

20. PwC 20
Classical integrated NHS- type system
Central government
Population
General taxation NHS = payer &
provider
Limited choice Public providers
Main characteristics of the Beveridge model

21. PwC 21
Traditional CEE model
Nikolai Aleksandrovich Semashko

22. PwC 22
Main characteristics of the CEE model
The healthcare systems in 1990
Central government
Population
General taxation
Hierarchical
subordination &
limited resource
allocation
Limited choice
Public providers
(hospital be numbers
high, provider incentives
low)

23. PwC 23
Regarding to the previous models and the relative position of the European
countries in relation to public and private expenditure on healthcare, does
countries can be positioned as follows
Source: Mercer Pan-European Health Care Survey 2008.
Social insurance model Tax-funded model

24. PwC 24
Healthcare reforms have been a constant phenomena in Europe over the
last years
Controlling the
cost of health
care
Improving
coverage and
access
• Broadening the population that
receives health care coverage,
through either public-sector
insurance programs or private-sector
insurance companies.
• Expanding the array of health care
providers for more consumer choice.
• Improving access to health care
specialists.
• Improving the quality of health care.
• Shifting cost from the state to
employers and individuals.
• Seeking to reduce the costs of
delivering health care – restructuring
service provisions and negotiating
terms with health system providers
such as private hospitals and
pharmacies.
Reforms typically focus in two broad areas:

25. PwC 25
Main reforms in European bismarckian countries
• Social security reimbursement has
fallen from 80% to 78%.
• In January 2011, a new 3,5% tax and
increase on the private health
insurance premium tax were
introduced.
France
• The Health Insurance Act that came
into effect in 2006 has the following
key elements:
o Citizens can change insurers
every year.
o People with low incomes receive
compensation for care.
o Customers and insurers
stimulate suppliers to provide
better quality.
The Netherlands
• In 2010, Germany´s cabinet
approved a controversial health
reform bill that raised employer and
employee contributions rates as of 1
Jan 2011 and allows insurers to
increase employee premiums as
needed.
Germany
• Healthcare reform is planned, the key
goals will include:
o Development of national goals.
o Focus on prevention an
promotion.
o Restructuring of hospitals.
o Tools to measure the quality of
the health system.
Austria
Source: Healthcare reform in Europe. Paul Ashcroft, 23 March 2011.

26. PwC 26
Main reforms in European beveridgian countries
• In 2011, the main government-run
insurer announce the single biggest
price increase in the history of the
market, premiums for employers and
individuals using the Voluntary
Health Insurance program will rise
by up to 45%.
Ireland
• Tax deductions for health care costs
have been limited.
• The NHS budget decreased by 12%,
and reduced NHS expenses are being
sought through 10 measures, such as
a 6% decrease in prescription prices,
cost controls, improved management
and shared services.
Portugal
• Under the reform plans of 2011,
family doctors are being given much
more responsibility for health
spending because the government
wants groups of general practitioners
to replace primary care trust.
United Kingdom
• Budget reduction in all autonomous
regions due to the crisis.
• Important control measures of
pharmaceutical expenditure.
Spain
Source: Healthcare reform in Europe. Paul Ashcroft, 23 March 2011.

27. PwC 27
Main reforms in European CEE countries
• In 1993/94, the Czech Republic moved to
a multiple insurance system.
• High rates of economic growth permitted
the establishment of a generous statutory
health car system in 1997.
• In 2008, the Civic Democratic Party
introduced user fees with the aim of
limiting consumption of medical
services.
Czech Republic
• Poland split its national health service
into several provincial health services. It
was only in 1999 that funding and
provision were separated by establishing
one health fund for each province.
• In 2003 all health funds were merged
into a single national insurance fund.
• The provider side is very concentrated
and possibly over-integrated.
Poland
• Since 2000, privatization of GP surgeries
is encouraged.
• In 2007, members if the governing
coalition reached a compromise on a
multiple insurance system. The
arrangement, called for the compulsory
health insurance to be managed by 22
health insurance funds with joint public-
private ownership.
Hungary
• In 1992 Romania began to slowly
decentralize public administration.
• Romania has faces issues such as an
underfunded National Health Insurance
Fund, migration of medical staff and high
out of pocket payments.
Romania
Source: Healthcare reform in Europe. Paul Ashcroft, 23 March 2011.

28. PwC 28
There are new phenomena in the public sector in Europe
1. Competition among insurers: Germany, Netherlands and
Switzerland.
2. Hospital privatization in Germany.
3. Hospital privatization in Netherlands.
4. The Nordic case: redesign of the classical Welfare State.
5. PPPs in Spain.

29. PwC 29
Only three countries in Europe allows citizens to acquire private health
insurance without still having to pay premiums or taxes to cover health
risks under the official system
• Germany has a sickness fund system.
People who earn more than a certain
income are allow to leave the funds
and buy healthcare insurance on the
market.
• About 10% of the Germans have done
so.
• Is the only country in Europe with a
healthcare system more akin to private
than a social insurance.
• All health insurance is private.
• The Health insurance Law defines the
catalogue of benefits to which all Swiss
insurance members are entitled.
However, individual insurance funds
can offer additional benefits over and
above this basic package.
• There is a compulsory
government-regulated,
single-payer system for
the expensive health risks
and a sickness fund
system for the other risks.
• One third of the
population is privately
insured. Once the Dutch
have an income above a
certain threshold, they
have to leave the sickness
fund and are supposed to
provide for themselves.
1. Competition among insurers: Germany, Netherlands and Switzerland.

30. PwC 30
In relation to the hospital privatisation, a clear trend to privatization is
perfectly obvious in Germany
Hospital ownership 1991-2008
• Between 1991 and 2008
the proportion of for-
profit hospitals in
Germany increased
from 15% to 30%.
• Next to purchase
hospitals completely,
new forms of public-
private partnerships
have evolved. One of the
trends is to contract out
the management of
public hospitals to
private companies.
2. Hospital privatization in Germany.
Source: Statistisches Bundesmat 2008.
Nº of hospitals

31. PwC 31
In Netherlands, for-profit hospitals will be permitted
• Healthcare legislation
traditionally contained a
formal ban on for-profit
hospitals.
Traditionally
Nowadays
• For-profit hospitals will be permitted in
order to make it easier for hospitals to
attract capital resources on investment.
• However, there will be restrictions to the
extend hospitals can pay their shareholders
a return on investment.
• The basic principle is that profits must be
reinvested in hospital care.
• According to a survey carried out for the
Institute of Health Policy and Management,
the Dutch are not opposed to the
introduction of private capital into
healthcare.
3. Hospital privatization in Netherlands.

32. PwC 32
The concept of Nordic welfare state model being redefined
4. The Nordic case: redesign of classical welfare state.
• By 1994, more than half of the 26 Swedish
county councils al the time had introduced
some form of purchaser-provider model.
• The number of people purchasing
supplementary private insurance is rapidly
increasing, from 2,3% of the population in
2004 to 4,6% in 2008.
• When St. Göran Hospital was sold to a private
corporation in 2000, it became the largest
privately owned hospital in the Nordic region.
• The so-called Stockholm model was based on
using the DRG system as a basis for payment.
The use of ABF was introduced in Swedish
health care in combination with other
management reforms.
• A purchaser-provider separation was first
introduced for nursing and care services in the
early 1990.
• The first private commercial hospital was
established in 1985.
• Norway implemented ABF for somatic
hospital services based in the DRG system.
• No major efforts have been made to introduce
purchaser-provider models in Denmark.
• The first for-profit hospital was establish in
1989.
• The pharmacy monopoly was changed,
allowing a small, but gradually increasing,
number of over-the-counter drugs to be sold
by, for example, supermarkets.
• In the early 1990s, the municipalities allowed
more freedom in terms of purchasing services
from public, non-profit and for-profit
providers.
• Private health insurance plays a modest role.
• No national financing model has been
introduced.

33. PwC 33
In Spain, the NHS collaborates with the private sector by three means:
Public contracts, Public Private Partnerships and Muface System
5. PPPs in Spain.
Public Contracts
Public Private
Partnerships
Muface System for
state employees
The NHS assigned in 2009 3,570€M to agreements with for profit (2,030€M) and not
for profit (1,540€M) private hospitals
• Singular contracts:. e.g. POVISA (Vigo), Fundación Jiménez Díaz (Madrid), various
hospitals of the Orden de San Juan de Dios, various hospitals in Catalonia, etc.
• Contracts for specific healthcare services. e,g. ambulance services, home oxygen
services, dialysis, rehabilitation, physical therapy, etc.
• Contracts for specific diagnostic tests or therapies in order to reduce waiting lists.
e.g. diagnostic imaging (MRI, CAT scans, PET, mammograms, etc), and surgical
procedures amongst others. Usually these contracts have very different durations, from
months to 4 or 5 years.
• Spain currently has 6 hospitals operating under the PPP model (5 in Valencia and 1 in
Madrid) with the opening in the next few months of three new hospitals in Madrid
(Móstoles, Torrejón y Collado), in addition to a new Radiation Therapy center in the
Canary Islands.
• The healthcare company Ribera Salud, the private hospital group Capio Sanidad and
private insurance companies (Adeslas, Asisa, Sanitas y DKV) are the key players.
• In addition, Madrid has entered in a PPP with Ribera Salud for a Central Laboratory that
provides services to 7 public hospitals and is looking to expand service to other hospital.
• The public administration provides health care coverage for approximately 2 million civil
servants: MUFACE, MUGEJU and ISFAS through Muface System.
3,570€M
586€M
1,400€M

34. PwC 34
In Spain, PPP models are transforming hospital market. Only in Madrid,
there will be in 2013, 11 hospitals built or managed under this type of
contract
Source: DBK, PwC Analysis
7 hospitals in
Madrid (PFI)
4 hospitals in
Madrid (PPP)
3 hospitales in Alicante
2 in Valencia ( PPP)
1 hospital in Burgos (PFI)
1 hospital in Mallorca (PFI)
1 hospital in Salamanca
(PFI)
1 hospital in Baix
Llobregat
(PFI)
Public-private partnership hospitals in Spain
Private financing initiatives (PFI)
Public-private partnership (PPP)
1
2
Hospital Nº Beds Participants Oppening Awarding (€m)
De la Ribera 301 Adeslas 1999 63
Ribera Salud
ACS
Lubasa
Denia 132 DKV 2008 97
Ribera Salud
Torrevieja 250 Ribera Salud 2006 80
Asisa
Acciona
Infanta Elena 106 Capio Sanidad 2007 nd
Elche-Crevillente 273 Ribera Salud 2009 146
Asisa
L'Horta-Manises 319 Sanitas 2009 137
Ribera Salud
H. de Torrejón 250 Ribera Salud 2011 n.d.
Asisa
Concesia
FCC
H. de Móstoles 260 Capio Sanidad n.d. nd
H. Collado Villalba 150 Capio Sanidad n.d. nd
Hospital Nº Beds Participants Oppening Awarding (€m)
Son Dureta 900 Dragados, FCC Under constr. 635
Baix Llobregat 238 Emte, Teyco, Acsa, La Caixa 2009 nd
Burgos 678 Grupo Norte, OHL, cajas ahorros Under constr. 242
Salamanca 912 nd nd nd
Henares 194 Sacyr Vallehermoso, Testa y Valoriza 2008 93
Infanta Sofia 283 Acciona y Crespo y Blaco 2008 98
Sureste 125 FCC, OHL y Cajamadrid 2008 49
PPP hospitals
PFI hospitals
5. PPPs in Spain.

35. PwC 35
Main European Healthcare PPPs since 1997
6. PPPs in Europe.

36. PwC 36
Main European Healthcare Privatizations since 1999
6. PPPs in Europe.

37. PwC 37
Hospital privatization drivers
• The cost pressure on market participants in the hospital sector is intensifying.
• Inefficient hospitals and facilities under a structural handicap will increasingly be
unable to cope with that pressure.
• But the populations demands on the state are increasing.
• This means that the state must be very careful in allocating its limited financial
resources as these are urgently needed for a variety of other public tasks besides
healthcare, such as education and unemployment relief.
• Against this background, the number of public hospital owners who wish to sell their
hospitals will continue to rise. For example in Germany the number of public hospital
owners is predicted to fall by 25% over the next 15 years, from the current total of
2,258 to 1,700, with most of them being owned either by private companies or by
non-profit organizations (Source: British Medical Journal, 2004).
6. PPPs in Europe.

38. PwC 38
Hospital privatization options
• Governments exploring hospital privatization have several options, depending upon
the nature of the region's present system and the external market area. They might:
o Sell the hospital asset to a private company;
o Lease it to a private management firm;
o Enter into a joint operating agreement (whereby the government relinquishes
direct management of the hospital but maintains a presence via board
members);
o Begin a joint venture, where both private and public sector partners maintain
ownership of the hospital;
o Start a public private partnership (where government sells the hospital, but
purchases back bed space); or
o Engage in comprehensive outsourcing of hospital duties.
6. PPPs in Europe.

39. PwC 39
Hospital privatization pros and cons
• Privatization of public hospitals can sometimes be daunting:
o It involves crossing a minefield of regulations;
o Selecting the best structural arrangement to meet local goals;
o Negotiating the best deal possible; and
o Handling union and sometimes public opposition.
• But done correctly, privatization has proven it is worth the effort.
o It can eliminate waste;
o Save resources;
o Reduce debt; and
o Create a better healthcare system for those who need it most.
6. PPPs in Europe.

40. PwC 40
Main issues of European private
healthcare sector
3

41. PwC 41
The European Union consists of 27 member states, varying in size and
purchasing power
Source: OECD Health Data 2010
In red the countries with more purchasing power.

42. PwC 42
Various differences exist between European countries
• Market size.
• Buying power.
• Growth/outlook.
• Innovation.
• Corporate
taxation.
• Currencies.
• Subsidies/
incentives.
• Etc.
• Labor laws.
• Intellectual
property.
• Patents.
• Export/import.
• Etc.
• Language.
• International
orientation.
• Business
practices.
• Etc.
Economics Finance Legislation Culture

43. PwC 43
Total healthcare expenditures are greater in those countries with a
healthcare model different from the NHS (universal coverage), such as
France, Switzerland or Germany
0
1
2
3
4
5
6
7
8
9
10
11
12
7.0%
2.1%
9.0%
6.5%
2.5%
Nether.
9.0%
7.4%
1.6%
Iceland
9.1%
7.6%
1.5%
Italy
9.1%
9.9%
7.1%
2.8%
Sweden
9.4%
7.7%
1.7%
Greece
9.6%
5.8%
3.8%
Denmark
9.7%
8.2%
1.5%
Portugal
Ø 9.4
Czech
Republic
7.1%
5.9%
1.2%
Luxemb.
7.2%
6.5%
0.7%
United
Kingdom
8.7%
7.2%
1.5%
Ireland
8.7%
6.7%
2.0%
OECD
8.9%
6.5%
2.4%
SpainBelgium
10.2%
7.4%
2.8%
Austria
10.5%
8.1%
2.4%
Germany
10.6%
8.1%
2.5%
Switz.
10.7%
6.3%
4.4%
France
11.2%
8.7%
2.5%
Public healthcare expensePrivate healthcare expense
Healthcare expense as % GDP, 2008
Source: OECD Health Data 2010

44. PwC 44
The role of the private insurance varies according to the country
Source: OECD.
* Portugal: 2008 data.:** Netherlands: 2007 data.
Current expenditure on health (%), 2009
20%
19%
7%
13% 12%
20%
6% 15%
27%
20% 17%
30%
10%
1%
0%
5%6%4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
United
Kingdom
84%
1%
Switzerland
19%
41%
9%
1%
Sweden
81%
0%
2%
Spain
69%
5%
5%
1%
Portugal*
64%
5%
3%
Norway
72%
12%
1%
Italy
78%
1%
1%
Ireland
74%
1%
11%
2%
Germany
9%
68%
9%
1%
France
5%
72%
13%
1%
Finland
60%
15%
2%
Belgium
11%
64%
5%
0%
Netherlands**
5%
77%
6%
General governmentSocial security fundsPrivate insurancePrivate households out-of-pocket exp.Other

45. PwC 45
Private hospital groups continue to grow and play a larger role in the
provision of care to a varying degree in different countries
32
3740
53
6267
100
110111
0
20
40
60
80
100
120
Nuffied
Hospitals
Spire
Healthcare
SanaRhön-
Klinikum
Helios
Kliniken
General
Healthcare
CapioGénérale
de Santé
Asklepios
(1) Data from 2010 (2) Helios Kliniken average size per hospital is not representative as the specialize in small hospitals including specialty hospitals for rehabilitation and elderly care.
(3) Total revenues include revenues from all sources (inpatient and outpatient) and therefore varies across companies depending on the mix of inpatient and outpatient services and
impacts revenue per bed calculations.
Source: MSI Data Report Hospitals: Europe (2011); Companies' websites
Number of Hospitals by Major Private European Hospital Groups
Headquarters
Turnover €
million FY09
2,163 2,046 1,650(1) 935 1,200 2,320 1,254 696 617
# beds FY09 18,030 16,000 n/a 2,907 1,400 n/a n/a 1,779 n/a
Beds/Hospital 162.4 145.5 n/a 43.4 22.6(2) n/a n/a 48.1 n/a
Revenue/Bed
(€K)(3) 120.0 127.9 n/a 321.6 857.1 n/a n/a 391.2 n/a

46. PwC 46
Some of the main companies involved in the healthcare sector in Europe are
the follows
Company Major presence in Europe Type
Alliance Medical Group
Germany, Ireland, Italy, Netherland,
Poland, Spain, UK
Provider of outsourced
diagnostic imaging services
Ambea Sweden, Finland, Norway
Provider of healthcare and care
services
BUPA UK, Spain
Private medical health insurance
plans
Diaverum
Estonia, France, Croatia, Czech Republic,
Greece, Hungary, Ireland, Portugal,
Poland, Romania, Russia
Renal healthcare company
Euromedic International
Bosnia, Bulgaria, Croatia, Czech Republic,
Greece, Hungary, Ireland, Portugal,
Poland, Romania, Russia, Turkey, UK
Medical service provider
Fresenius
Austria, Belgium France, Germany, Italy,
Sweden, UK, Spain
Renal care company
Labco
France, Italy, Germany, Spain, Portugal,
Belgium
Medical diagnostic group
Generale de Sante France, Italy
Provider of private hospital
healthcare services
Jose de Mello Saude Portugal, Spain Provider of health services

47. PwC 47
New players: private equity
companies
4

48. PwC 48
There are some drivers that govern the focused of the private equity
companies in the European sector
Market fragmentation (hospitals, long-term care, diagnostic)
Changing regulatory environment
Improving infrastructure in CEE
Increase in the number of private operators
Consolidation opportunities

49. PwC 49
Date Target Description Bidder Country Type %
Deal Value
(€ M) EV/EBITDA
Jul-10 Centro Medico Teknon Health and allied services, nec
Magnum Capital
Industrial
SP F 100 140,0 9,3 x
May-09 USP Spain Hospital operator Barclays and RBS UK F 65 n.a.
Jul-07 USP Spain Hospital operator Cinven Group UK F 100 675,0 18,1 x
Date Target Description Bidder Country Type %
Deal Value
(€ M) EV/EBITDA
Feb-10 Southmead Hospital It owns and operates hospital. Investor Group UK F 100 497,2
Mar-08 Cromwell Health Group Ltd It owns and operates hospital.
British United
Provident Assoc
UK I 100 114,4
Apr-08 Classic Hospitals Ltd Owner and operator of hospitals.
Spire Healthcare
Ltd
UK I 100 192,5
Dec-07 Nuffield Hospitals-Hospitals Nine hospitals around UK.
General
Healthcare Group
UK I 100 195,7 12,7 x
Nov-07 Capio Healthcare UK Owner and operates hospital
Ramsay Health
Care Ltd
AU I 100 285,2 7,9 x
Sep-07
Spire Healthcare
(BUPA Hospitals)
Owner and operator of hospitals. Cinven Group Ltd UK F 100 2458,0
May-06
General Healthcare Group
PLC
Own and operate medical and surgical
hospitals.
London & Regional
Properties
UK F 100 3162,6 12,0 x
Date Target Description Bidder Country Type %
Deal Value
(€ M) EV/EBITDA
Mar-10 Groupe Proclif SAS It owns and operates private hospitals.
Ramsay Health
Care Ltd
AU I 57 87,0
Oct-09 Cliniques Privees Associees French hospital management company.
Vivalto Sante
(Credit Agricole)
FR F 100 63,0 5,8 x
Jul-09 Groupe Proclif SAS Owns and operates private hospitals. Predica SA FR F 43 70,0
Sep-08
Generale de Sante SA-
Hospitals
It owns and operate hospitals & specialty
hospitals.
ICADE SA FR I 100 201,7
Nov-06 Tonkin Investissements SA It owns and operates private hospitals. Capio AB SE I 100 146,0 10,4 x
Jan-06 Arvita SA Private hospital operator. Capio AB SE I 100 71,0 7,1 x
Source: Thomson, Merger Market
Spain Sweden
France
United Kingdom
Switzerland
Date Target Description Bidder Country Type %
Deal Value
(€ M) EV/EBITDA
Mar-10 Ambea Health and allied services, nec Triton SE F 75 850,0
Sep-06 Capio AB Diagnostic services, healthcare services
Opica AB (Apax
Partners)
SE F 100 2460,0 13,8 x
Date Target Description Bidder Country Type %
Deal Value
(€ M) EV/EBITDA
Oct-07 Klinik Hirslanden AG
Owner and operator of
hospitals.
Medi-Clinic
Luxembourg Sarl
LU I 100 1724,9
Date Target Description Bidder Country Type %
Deal Value
(€ M) EV/EBITDA
Mar-10 Krankenhaus Siegburg It owns and operates a hospital.
HELIOS Kliniken
GmbH
DE I 100 22,0
Nov-09 MEDIGREIF Five clinics as well as two medical care centers.
Rhoen-Klinikum
AG
DE I 94 106,0
Sep-06 Klinikum Uckermark GmbH Own and operate a hospital
Asklepios Kliniken
Verwaltungs
DE I 94 20,0
Germany
F: Financial; I: Industrial.
*
• Few cross-border deals
• Few international hospital networks groups
• Recent trend towards the acquisition of individual assets
Relevant comparable deals by country

50. PwC 50
0,00x
2,00x
4,00x
6,00x
8,00x
10,00x
12,00x
14,00x
16,00x
18,00x
20,00x
ene-06
mar-06
may-06
jul-06
sep-06
nov-06
ene-07
mar-07
may-07
jul-07
sep-07
nov-07
ene-08
mar-08
may-08
jul-08
sep-08
nov-08
ene-09
mar-09
may-09
jul-09
sep-09
nov-09
ene-10
mar-10
may-10
jul-10
31
Capio acquired
Arvita
(7,01x EBITDA)
Bain Capital, KKR & Merrill Linch acquired
Hospital Corporation of America
(12,10x EBITDA)
Opica (Apax Partners)
acquired Capio
(13,80x EBITDA)
UNCN acquired
USP International
(8,90x EBITDA)
Crestview Partners
acquired Symbion
Healthcare
(8,90x EBITDA)
Community Health
Systems acquired
Triad Hospitals
(10,56x EBITDA)
Ramsay Healthcare acquired
Capio UK
(7,90x EBITDA)
Primary Healthcare
acquired 80% of
Symbion Health
(10,26x EBITDA)
Star Healthcare acquired
Terveystalo
(12,48x EBITDA)
Vivalto Sante acquired
Cliniques Privees Associees
(5,75x EBITDA)
RehabCare acquired
Triumph Healthcare
(6,36x EBITDA)
Cinven Group acquired USP
Hospitales
(18,10x EBITDA)
General Healthcare Group
acquired Nuffield (9 hospitals)
(12,7x EBITDA)
Magnum Capital acquired
Centro Médico Tekon
(9,33x EBITDA)
EV/ EBITDA
Relevant transactions in Europe

51. PwC 51
Challenges of European health
systems
5

52. PwC 52
Healthcare sector is facing some challenges that will condition its future
evolution
Ageing
Increase in healthcare expenses
Chronic illness in a system designed for acute diseases
European economic recession
Legacy healthcare structure
IT interoperability
Changing legal environment

53. PwC 53
Main trends of healthcare systems in
Europe
6

54. PwC 54
Main trends of the healthcare in Europe
Development of healthcare to prevention-promotion
Personalized services - personalized medicine
Deep impact of information and communication technologies and exponential
growth of health information
Changes in patient role
Regulatory changes and healthcare reforms
Public private partnership
Primary care will become more important
Appearance of global or transnational players (healthcare insurance and
providers)

55. PwC 55
SWOT Analysis
Strengths Weaknesses
Opportunities Threats
• Improving healthcare awareness.
• Availability of skilled workforce.
• Government´s commitment to
healthcare industry improvements.
• High dependence on the import of
hi-tech technology.
• Manufacturing and R&D activities
looking for other areas (US, Asia,..).
• Harmonization with the EU.
• Healthcare reforms.
• Public private partnership.
• PE are very interested in the healthcare
industry.
• New global or transnational players.
• Advances towards IT interoperability.
• Negative effect of government prices
controls/reimbursement lists on
market attractiveness.
• Slow pace of the reforms.

56. 56
Obrigado