Bumrungrad Hospital Public Company Limited (BH) Earnings Call Transcript & Summary

Welcome to the fourth quarter 2021 and full year 2021 Analyst Presentation. I'd like to begin first by announcing our latest proudest achievement and being recognized by Bangkok Post as the top-rated most trusted health care providing brand in Thailand. It is yet again another series of achievements that recognizes our dedication to high-quality health care, patient safety and excellent clinical outcomes at Bumrungrad, for which we are synonymous around the globe with. Our latest agenda, we will begin first with -- we recently signed an MOU with Carnegie Mellon University, King Mongkut's Institute of Technology Ladkrabang or CMKL. This is a collaboration between the world-renowned Carnegie Mellon University based in the United States and the King Mongkut's Institute of Technology Ladkrabang for which it is well known in Thailand in providing high-quality education in the technology or technical areas and sciences. The reason for this MOU is to support our growing need for talent in the areas of AI and data science to support many of the projects that we have described in the past. If you recall in the previous year, we talked in the first quarter about the hospital's goal of moving towards becoming a smart, digitally rendering health care hub. And in it, the provision of the digital twin to support health care on a virtual, on a precision or genomic level and also to become more proactive in managing people's health and their risks to help to diseases and other ailments. This MOU will allow us to access talent to support these key strategic initiatives for the long-term. Moving on to the 2021 snippets. I'd like to daylight once again some of the key revenue drivers for the quarter, and there were many. The first was the 1 Card loyalty program for which we have now been in partnership for a while. And the 1 Card has continued to expand our access to new patients and drive new patient volumes to come to the hospital for health care. And it amounted approximately to nearly THB 1.3 billion in terms of direct accretive value to the organization, a growth of approximately 194% year-on-year. COVID-related revenue as a whole in 2021 was around THB 706 million, an increase of around 477% year-on-year. On telemedicine and home care revenue is something that we've talked about quite often and many people ask, how will that play out in the long-term. We saw an increase of 28% year-on-year growth amounting to nearly THB 450 million. Telemedicine is clearly here to stay, and it will be part of one of our pillars in delivering care to our patients. It's significant to note, though, that whilst telemedicine provides easy access to people and to doctors, especially during COVID period, there has been somewhat of a decrease in demand as the country opened up. And that was something we daylighted to you when the country would open up and people would prefer to come in person for health care to see their doctors physically to come to the hospital for treatment. Nonetheless, the trend is quite sustained, and we are continuing to invest and grow this side of the business, and we expect to see additional growth in the future. On referrals from other hospitals, another key segment for us and another highlight for us and why we, as an institution are one of the key primary -- one of the key health care providers for the country for high-quality health care services in the private sector. That segment grew 11% year-on-year and amounted to over THB 400 million. Online and digital products. This is something we have talked about in the past, and the volume of growth is quite significant, 88% year-on-year, amounting to around -- almost THB 370 million for the year directly indirectly the effect of digital marketing and MarTech departments have been significantly higher in helping to gain access to patients through the digital sphere and to also drive interest, drive content for our patients. We talked in the past about discounting about promotions and why we, as an institution, had to incentivize our patients during the COVID period to come to the hospital. We provided a number of programs that aim to entice them to come to the hospital. And this was not something that was in isolation. Many other hospitals have done that, too. But in Bumrungrad, I would like to illustrate that the effect of that discount has been significant, both in terms of discounting the gross revenue generated by the hospital to the net revenue that we display on our financial statements. If you look at the fourth quarter, that amount was around 17.6%, which if you compare with the overall average for the 2 years prior to COVID affecting the country in the world, the average discount rate was around 9.5%. We do expect that these discounts to run costs to medicine to diagnostic tests will decrease as these have expired at the end of the year, and we do expect this to start to normalize to more average levels. This uplift in net revenue when one calculates will be a significant contributor in the future for the hospital, and we are keen to see a more normalized rate of discounting, especially as we've seen a pickup in demand over the last several months. Now I'd like to hand over this presentation to Neil Sorrentino, our Chief Global Strategist, who can give you more color on the developments of the quarter. Thank you.

Welcome to Bumrungrad Hospital Public Company Limited Q4 Analyst Presentation. Thank you for joining us this morning. Well, the quarter was marked by extensive and highly diversified revenue from many, many different sectors. The performance in the quarter beat even our internal expectations of what we thought it would be like even after the country opened up, which it did in Q4, closed down a little bit at the end of the quarter, but nonetheless, it was a very, very strong quarter for Bumrungrad International. Let's talk about the pieces of it, and I'll go through it in the way of looking at essentially takeaways for the quarter and then getting into some detail for you to give you some color about the about what composed the performance for the quarter. The NOPAT for Q4, to give you an idea of how strong the quarter was, NOPAT to the quarter equaled 50% of the total NOPAT for the entire year of our company performance, which tells you really how robust our challenge and our performance was in Q4. And a lot of it was driven by multiple business drivers, Middle East, Indo-China, and I'll talk a little bit about which countries drove that growth. But we also had quarter-over-quarter-over-quarter performance, both from our Thai business and our expat business, and I'll go into that in a bit of detail. In terms of the other takeaways for the quarter, we paid off the remaining amount of THB 2.5 billion of our long-term debt, approximately at 5% interest expense percentage, 4.97. And the significance of that is that it will represent about THB 124 million in expense savings uplift on interest costs for 2022, and it's significant and it's material. But at the same time, as you see here on the takeaway slide, we still after that buy down and finishing off of the long-term debt payoff. We wound up at the end of January with THB 6.04 billion in free cash flow. Part of that was due to excellent trade receivables collections for the quarter. In large measure, in the Middle East, we asked our Middle Eastern sponsors and guarantors to please get caught up by year-end. They like to do that because if you're not asking them to make these payments in the -- especially at the end of the fourth quarter, they run on a zero-based budget basis and typically would say, well, that was money that was in the prior year. Now you're asking us to pay receivables that were accounted for in the prior year in the next year, and it's a little bit more difficult to collect those trade receivables. So we knew that, and we were respectfully aggressive in collecting trade receivables. And we brought our AR days down by 20 days, it was material, which drove the THB 6 billion of free cash flow after the long-term debt that was paid off. I'll talk about the guidance later on in my presentation, and then I will talk about the dividend payout that our Board will be recommending to our shareholders of record on April 27. Next slide, please. So here I put together for you a trend line of the revenue, EBITDA and NOPAT for the year by quarter. And you see the wavy lines going in a very positive direction to the northeastern direction, which is always good when you're looking at trend lines. And you see quarter-by-quarter-by-quarter, just what the revenue did, what the EBITDA did and the net profit did. I'm not going to read you the numbers because you have the presentation with you and in front of you. But what does it say? It says in summary, that each one of the following quarters after Q1 showed stronger and stronger growth. And as I mentioned earlier, the diversification of the business drivers that are producing this revenue, EBITDA and net profit were really very widely distributed throughout the quarter and I'll get into that in just a moment. I will mention before I swing past this slide that in the quarter of Q4, we took a write-off on an investment we made in the telemedicine company, we bought an interest in of 30% back in 2000, I believe it was '18 in the form of iDoctor, the name of the company. We did sell our interest in iDoctor. It's at a level of about USD 170,000, the balance of which against the cost of the acquisition, which was about THB 80 million, the balance of which was THB 56 million. We took that write-down in the quarter. So if you look at the net profit line, the bottom line there on this slide, the brown line, you will see where I reflect for you out of operations, what the net profit was before we took that write-down, and that number was THB 668 million of NOPAT after the write-down, it was THB 612 million. And I'll talk a little bit about that in a moment as it reflected and affected the margins. Okay. Next slide, please. So let's look at the business segments of the market. Again, outstanding quarter-over-quarter growth, 33.8%, well above your expectations, I'm sure. And honestly, above our expectations. It was just an outstanding quarter for us in year-over-year change, almost similar percentage growth to 33.1%. Next slide. So on all international and the biggest drivers here of all international were Middle East and Indo-China, our Indo-China sleeve of countries, meaning Myanmar, Bangladesh, Cambodia, and some effect associated with the expat business in this country in China in the United States has a number of U.S.A. expats who work here. I'll address that in a little bit how it affected the differences in expat revenue from quarter-to-quarter, Q3 to Q4. Next slide. So let's look at the changes in the quarter as a percentage. So you see here Kuwait, Qatar, Myanmar, Cambodia, UAE. The percentages are very, very large quarter-over-quarter, but they really don't tell the entire story. Bangladesh was a very strong quarter for us. The U.S., I mentioned earlier, these are not necessarily U.S. citizens coming to Thailand. There were some, but a lot of this has to do with expats here in Thailand or expats who are corporate executives that were delayed in coming to Thailand because the country was closed in Q3, but opened up in Q4 and then they started coming back. And they're an important piece of our expat business to us because they're well insured. They seek out the best care. They can afford the best care. And as Daniel has mentioned already, with the most trusted brand in all of Thailand, and we're humbled by what Bangkok Post gave us as an award for that. They'll seek that kind of top quality care, and we get a lot of USA expats here. Oman was also a big percentage, but let me give you some numbers associated with the revenue growth changes. So you understand better what that dynamic really was. So I'm going to read you some countries now to talk about the change in the revenue Q3 to Q4, United Arab Emirates in Q3, our revenue was THB 16.7 million. In Q4, the UAE revenue was THB 73.2 million. Oman, in Q3, the revenue was THB 7.7 million in Q4 was THB 55.8 million. In Qatar, the revenue was THB 115 million in Q3. It was THB 134 million in Q4. Saudi Arabia was THB 6.1 million versus THB 10.3 million in Q4. And on, it goes where the differences in all international was THB 333.5 million in Q3 and the uplift by the country opening up was THB 519.2 million. Now those numbers are important, but what's even of greater importance is the level of illness and the drive associated with the revenue intensity of these kinds of patients. And this is our calling card. This is what we're noted for. And I have been telling you, quarter through quarter through quarter during this terrible period of COVID pandemic that we have seen a lot of pent-up demand from these countries. People wanting to come to Thailand, people wanting to come to Bumrungrad and we stayed connected to them. We communicated with them. We told them what our services were, and we've tried as best as we could to bring them here even under different circumstances even under quarantine, and even under lockdown. Well, Q4 when the country opened up, this is the result of that. I expect this kind of performance in terms of continuing flow of international patients coming to Bumrungrad to continue in 2022 in so far as the country remains open. As long as Thailand remains open and is moving toward an endemic status. I expect this level of support to continue. We were gratified that the patients still want to come to Bumrungrad, make it their first choice and couldn't wait to get here. Many of these patients are very, very ill. And what was also true in the quarter in terms of revenue intensity remained true historically, and that is, is that our international patients represent the revenue intensity differences of Thai and expat patients of 3:1, which is significant if you do the math associated with how many Thai and expat patients you need to make up the revenue intensity of one international patient. And it's logical because these patients sometimes come -- many times come without conditional care in their own country because they don't have these services there and come here and fly here and they're quite sick, and they need pretty significant diversified medical or surgical intervention. Next slide, please. So I mentioned the Middle East on its own, it changed was 55.7% for the quarter over Q3 and year-over-year was almost 60% differential. And go back -- and it includes the countries, the Middle Eastern countries that are listed at the bottom of this slide that we're showing you. Next slide. IndoChina was very strong at 187%, and I'm going to give you the revenue changes just as I did for the Middle Eastern, but you can see the percentage growth, 187% for the quarter-over-quarter, 3% to 4% to 3% and 175%. Let me give you those numbers to give you the magnitude of the -- where the contribution was coming from by revenue changes by country. Q3 in Myanmar, the revenue was THB 62.3 million. Q4 was THB 207.6 million in revenue from Myanmar alone. Bangladesh in Q3 was THB 5.8 million. In Q4, it was THB 79 million. Cambodia was THB 65.6 million in Q3, Q4, THB 129.3 million. And on it goes down the list of the IndoChina countries. I'm giving you these numbers, so you get a real clear sense of, as I've mentioned, through this presentation, the diversified impact on why Q4 drove 50% of the total NOPAT for the year of 2021. Next slide. The Q4 performance by the 5 top nationalities. There are the 5 countries by percentages, and I've mentioned them in giving you the actual revenue changes quarter-over-quarter, you can see it for yourself. Next slide. On the Thai business, moving to, if you will, the domestic side of the house up in the top left-hand corner there, I've provided for you the changes quarter-over-quarter. And we're proud of this as well in providing our Thai customers, clients and patients the services that they sought. And you can see from quarter-to-quarter-to-quarter, the growth in changes of that revenue, 37.4% versus Q1, meaning this is 4 against 1, 4 against 2 was 22.6%, 4 against 3 was 16.6%. Strong support from our Thai patient population in Q4. And of course, year-over-year, it was up almost 20%. And the effect of what Thai are seeking in the way of health care are not a lot different another lot different than what we see from our international patients, except it's more driven by routine medical care, routine surgical care, checkups, ophthalmology, pediatrics, OB/GYN, these are the services that Thai people were taking advantage of in the quarter when the country opened up. Expats is the next slide and why the growth in expats of Q-over-Q3 versus 4 was up 18%, our revenue. That was driven by one principal thing. And that's because in Q3 with the country shut down, there was a delay in corporate executives coming to Thailand because they couldn't get into the country. They work here, but employers were holding off on bringing these corporate executives in delaying their contracts, employment agreements or consulting agreements, but they came in large measure in Q4, and there's the translation of that additional amount of corporate executives coming into the country with an 18% growth in revenue. Next slide. So I presented this format to you before, and it may be a bit confusing. I'm going to spend a little bit more time talking to you about it so you understand better because a number of you have asked questions about AHQ, ASQ and in the quarter, we had Test & Go. So let's start on the right-hand side. On the right-hand side, under AHQ ASQ and Test & Go, you'll see percentages in purple. Now these circles represent the number of patients and/or encounters that have come to Bumrungrad, either through hospital quarantine through ASQ or through Test & Go. The percentages, 69%, 27% and 14% are these services that the same patients in each one of these categories said that after they went through this AHQ, ASQ process that the government required or the Test & Go process, they sought health care at Bumrungrad. So let me take you to the upper top part of this slide. And you'll see the difference in the quarter, THB 289 million versus THB 513 million. So you collect all of those percentages translated into revenue, and it equates to the differences between Q3 and Q4, dramatic, THB 289 million versus THB 513 million. And what was it as a percentage of total revenue? That's the bottom portion, bottom left-hand portion of the slide, which shows you over the period Q1 going back to Q1 '20 forward, and this is also a pleasing result for us because it represented 13% of our consolidated revenue which tells me, one, we're being favorably selected by people coming into the country for care; and 2, the conversion of care because they don't have to come to Bumrungrad once they go through an AHQ or ASQ for that matter or Test & Go for that matter, but they do to the extent of the difference between THB 289 million versus THB 513 million. So this is a good confirmation for us of how we're treating our international patients as they come in, especially the third piece of it now, which is the Test & Go part of it, which Dr. Thassanawut talked about earlier in his presentation, where will talk about earlier in his presentation. You will also hear some discussions for Q4 about our abilities as a quaternary care provider for those of you that may not be familiar, there's primary, they're secondary, there's tertiary and there's quantity. Quaternary care is the most integrated complex care that a hospital can provide. We have moved in 2021 into a major quaternary care facility. We have always been such at some degree. But now with our heart transplantation program and our kidney transplantation program and our corneal transplantation program, which will be discussed by others in this presentation for Q4, you'll get a better understanding of why we're spending so much time, money and manpower in developing further who we are as an organization in Thailand. Next slide, please. So now we move to the EBITDA and the NOPAT for the quarter. The numbers speak for themselves. I'm not going to go through it. You can see that versus Q3, the EBITDA was up 70%, 93% versus 2,171% Q1. It was just a remarkable quarter. Next slide. So I put this together for you to give you a sense of trend lines like I did at the beginning of the presentation. So they take you back to Q1 of '20. For those of you that may recall, Q1 of '20 there was 1 month out of the 3 months in the quarter that was truly affected by COVID. It was the beginning of COVID for Thailand. And even in that quarter, Q1, 2 out of the 3 months were very strong quarters for us, especially in a very strong months for us, especially from the Middle East. And in that quarter, our EBITDA margin was 29.9%. So we take you -- I take you here through all of the quarters from Q1 '20 to our fourth quarter and we almost touched the 29.9% number, which was the end of business as everyone knew it in the beginning of COVID to where 4Q 2021, we were not far from the 29.9%, and we recorded 28.4% EBITDA margin. And when you look at the trend line as low as 12.9% in Q2 '20, it just tells you all you need to know about our performance over the period. Next slide. Net profit, it's really the same story. Triple-digit positive triple-digit changes quarter-over-quarter. And as I said to you earlier, Q4 was 50% of the total net operating profit after tax for the company for the year. And this slide also shows you the difference between the sale of the iDoctor sale and write-down of the iDoctor investment both before and after. Next slide. So I'm doing the net profit margin trend lining for you to see the same pattern. Only this pattern because of excellent cost control in the quarter, and it was, it was excellent cost control in the quarter, notwithstanding excellent trade receivables reduction. But if you have a look here at the net profit margin for the quarterly trend line, you will see that in Q1 2021, the net profit margin was 3.4%. Now mind you, these are percentages, net profit margin percentages based upon a fairly high discounting that we're doing for domestic business. We will be moderating those discounts as time goes on as will everyone else who is doing similar things because of supply and demand issues. But mind you, even with those 17-plus percent discount, you can see here what the margin was in Q4, 15.6% reported after the write-down of THB 56 million for the iDoctor investment. Before it out of operations, it was 17%, again, touching almost close to 1Q 2020 of 18.5%. We expect this trend line to improve as well as we go through 2022, to the extent that Thailand moves into an endemic status in so far as COVID-19 is concerned. Next slide. So there were 2 items remaining that I wanted to draw your attention to in so far as my presentation or concern. One is guidance, which I will address lastly. The other item had to do with dividend payouts. You may recall, I have covered with you the interim dividend payout that was approved by our Board of Directors earlier in 2021. On Wednesday evening, past, our Board made the decision, unanimous decision to recommend to our shareholders of record at our Annual General Meeting on April 27. The recommendation to pay out 209% of 2021 EPS at about THB 1.53. So if you look at what that means in absolute total baht paid out, it will be identical in absolute total baht paid out to what was paid out in 2020 and 2021. Our Board has been consistent, as has our shareholders. They've been consistent in wanting to reward our loyal shareholders not only to the extent of historically giving 50% of actual EPS out. But in the last 2 years, 200% to 300% of that year's EPS to reward our shareholders. Fortunately, we've been able to manage our cash very, very well. We've been conservative about how we've dealt with cash. Our debt, as you know, is very, very, very low, now 0 long-term debt. So we will submit that as management and our Board of Directors to our shareholders at our 27 April AGM meeting waiting for their approval. And so far as guidance is concerned, let me address that in somewhat of a bit of a different way for you. As you know, we don't give go-forward guidance except top line revenue growth. The top line revenue growth in Q4 was 33%. And we are not in an informed calculating decisions to say we're going to beat 33% top line revenue growth in Q1 2022 because it was such a huge number. Not only that, but the number was coming off of a weak Q3 because of the COVID lockdown. But what I can say to you is that when we went through the 2022 budget exercise at the end of Q4 2021. We did come to certain conclusions as an organization about what the first half of the year would look like and what the second half of the year would look like. And we assumed that there would be gradual changes to the positive on volume, both internationally as well as domestically, trending upwards slowly, gradually, incrementally, in the first 2 quarters of 2022 and then increasing in Q3 and in Q4, similar to what we saw in 2019. Those are the budget assumptions we put together that are driving our business plan, that are driving our CapEx budget, and they still look quite sound right now. We'll amend them and modify them on a rolling 4 quarters forecasting basis as we get results in quarter-by-quarter. And we'll continue to update you about where we are with that. But a lot of it is dependent upon what happens with COVID. As you could see in the quarter, the strong support was there from our international business community to come to Bumrungrad. So it's not a function of the question, well, will international business come back to Bumrungrad. I think Q4 for you, we were always confident it would be for us. But I think Q4 for you, it's fairly clear that the support is incredibly strong. We expect that to continue. Once we get past Songkran, once we get past Ramadan, which this year happens to be April 1, Ramadan is 40 days, and then there's about a 10-day period of it, which is a celebration after Ramadan. Once we get past those, we're pushing toward the end of Q2, not quite, but almost. So we are projecting and hopeful that what I've just told you will be in line with what our performance will attract to. And that's probably the best I can give you an insight into guidance at the moment. We're not about to say we're going to be 33% revenue growth Q4 2021 versus revenue growth Q1 2022. That concludes my presentation for the Q4 analyst presentation. We will look forward and invite you to submit your questions during our live stream next week, and we'll try and answer all of your questions as fully and as completely as possible. Thank you for joining us.

Thank you, Neil. So we will move on to the financial highlights and dig into the details of our financial performance by Khun Oraphan. Khun Oraphan, please.

Good morning, everyone. I'm Oraphan Buamuang, Chief Financial Officer. I'm pleased to report you on the financial highlights and financial performance of fourth quarter 2021 and for the whole year 2021. Financial highlights. As the result of Thailand reopening in 1st of November 2021 by allowing fully vaccinated visitor from low risk country to enter to Kingdom of Thailand without quarantine together with the continued growth of Thai and expat business. In fourth quarter 2021 financial performance will improve when compared to fourth quarter 2020 and third quarter 2021 comparing to fourth quarter 2020 total revenue increased by 3.1%. EBITDA and net profit margin improved by 121.1% and 253.8% respectively, with EBITDA and net profit margin at 28.4% and 15.6%, respectively. In this quarter, we have an extraordinary item on loss from sale of investment in iDoctor THB 56 million. When excluding extraordinary items, the accepted net profit was improved by 286.5%. For the whole year result, financial performance of year 2021 were also improved from year 2020 total revenue slightly increased by 1.3% EBITDA and net profit increased by 6.3% and 1%, respectively, with EBITDA and net profit margin at 21.9% and 9.6%, respectively. For the net profit and diluted EPS exclude extraordinary items improved by 5.6%. I will walk you through more detail in the next slide half. Financial performance. In fourth quarter 2021, total renew increased by 33.1% mainly came from Thai patient and non-Thai patient revenue increased by 19.7% and 50.2%, respectively. For the whole year 2021. Total revenue increased by 1.3%, mostly due to an increase in Thai patient revenue by 12.3% offset with a decrease in revenue from non-Thai patient by 10.1%. In fourth quarter 2021, due to a 50.2% increase in revenue from non-Thai patient which is higher than Thai patient revenue increased at 19.7% as a result of revenue contribution from non-Thai was 50% increase from 44% in fourth quarter 2020. For the whole year 2021 due to 12.3% increase revenue from Thai patient offset with 10.1% decrease in revenue from non-Thai patient, as a result, the revenue contribution from Thai patient mark, 54% whereas revenue from non-Thai patient was 46% for the year 2021 compared with 48% and 52%, respectively, for year 2020. For renewal contribution by service. In fourth quarter 2021 revenue contribution from outpatients service increased to 53% due to [ OBIDA ] revenue increase by 46.3% by above [ EBITDA ] revenue increased by 25%. For the whole year 2021 revenue contribution from outpatient service increased to 49% from 48% in year 2020 due to [ OBIDA ] revenue increased by 5.7% while [ EBITDA ] revenue increased by 3.2%. For revenue contribution by payor type, self-payor contribution increased from 61% to 66% in year 2021, mostly due to increase in Thai and expat self-payor in year 2021. Insurance contribution remained portion at 21% in both of year 2021 and year 2020. The government third-party contribution in year 2021 decreased from 15% to 11% due to restriction on travel during the year, impact Middle East business, which are the major government sponsor. For EBITDA. EBITDA in fourth quarter 2021 was THB 1,160 million, improved from THB 7 million last year by 121.1%. EBITDA for the year 2021 was THB 2,756 million was above last year by 6.3%. The improvement mainly came from volume of revenue increased, plus the continued variety cost [indiscernible] program during year 2021, which consists of workforce management, contract management and inventory management. As the result, we could achieve cost saving THB 247 million in year 2021. For EBITDA margin in fourth quarter year 2021 was improved to 28.4% compared to 17.1% in fourth quarter last year. EBITDA margin for the year 2021 was also improved to 21.9% compared to 20.8% in prior year. For net profit in fourth quarter 2021 was THB 612 million improved from fourth quarter last year by 253.8% and adjusted net profit was THB 668 million improved from same period last year by 286.5%. Net profit for the whole year 2021 was THB 1,216 million, slightly improved from year 2020 by 1%. And the adjusted net profit was THB 1,272 million, improved from same period last year by 5.6%. For the net profit margin and adjusted net profit margin in fourth quarter 2021 were improved to 15.6% and 17%, respectively when compared to 5.9% in fourth quarter 2020. For year 2021, net profit margin and adjusted net profit margin was 9.6% and 10.1%, respectively, compared to 9.7% in year 2020. In terms of [ coverage ] ratio, net debt to EBITDA for the year 2021 was negative 0.6x due to less net debt after repayment, long-term debentures THB 2.5 billion in December 2021. Net debt to equity of year 2021 was negative 0.1x due to less net debt as well. For interest coverage ratio in year 2021, slightly increased to 21.6x due to EBITDA increase and less interest expense in this year. This is our financial performance of fourth quarter 2021 and for the whole year 2021. Thank you for your attention.

Thank you, Khun Oraphan. Our next part is the business update section, starting with Dr. Thassanawut, who will once again go through all the ways in which our international patients are coming into Thailand and seeking treatment in Bumrungrad. So Dr. Thassanawut, please?

I'm Dr. Thassanawut Dhearapanya, Division Director of Medical Transport and Business Development International. I'm so glad to see you all here today again. Today, I will be updating the travel regulations and restrictions for people coming into Thailand, may it be Thai nationals or foreign nationals alike. Currently, people who are coming into Thailand have to go through the Thailand pass process. For patients in particular, currently, they can opt for either the Thai Test & Go program or the AHQ program. As you can see right here, the exemption from quarantine option or so-called Test & Go, most of them are the OPD cases. If OPD patients would like to come and see the doctor in Bumrungrad International, they have to apply and submit their documents through the MOFA website, tp.consula.go.th. In order to get the Thailand pass currently, the RTPCR had to be done on 2 occasions. First one, on the first day of arrival and the second one on the fifth day. Luckily, yesterday, the CCSA or the center for COVID situation awareness of Thailand, who is holding the policy regarding the COVID-19 in Thailand, they announced that the fifth day RTPCR would be lifted starting from the 1st of March onwards. So that means people can decide easier to come into Thailand because now only 1 RTPCR on the arrival date is needed. Hence, the quarantine is virtually none. After the negative RTPCR on the first day is available, then they can just leave the hotel room. They can go anywhere in Thailand. Also, they can come to the hospital and seek for treatment. For the IPD or patients who need admission upon arrival, still the MOPH approval is needed. But now we can see for the approval very, very quickly, unlike the very earlier times of HQ virtually, we can get the approval within the same day. And then after they got the approval, they can submit these documents into the Thailand Pass website. And of course, they can come in and then undergo the quarantine as needed for the fully vaccinated 7 days and for the non-vaccinated 10 days. I can show you right here some of the stats. The last quarter of last year, we welcomed 217 cases into our hospital from abroad. In January alone, we welcomed 119 cases. For domestic patients, we are still looking forward to welcoming more patients in Thailand as well. In Thailand, in the last quarter of last year, we admitted 193 cases. And in January alone, we admitted 45 of them. As you can see, as the situation has eased up, the restrictions have been lifted Hopefully, we can welcome more and more patients, both domestically and internationally. And here, the revenue will grow. See you again. Thank you.

Thank you, Dr. Thassanawut. Slight deviation to what we have -- something new to what we have previously presented is our Organ and Tissue Transplantation Center, a key component in defining ourselves as a quaternary care center. I would like to hand the presentation over to Dr. Suwanna, who will talk further on this issue.

[Foreign Language]. I'm Dr. Suwanna Suwannaphong, Strategic Business Unit Head and Director of Organ and Tissue Transplantation Center of Bumrungrad International Hospital. We have done cases for quite some time. And last year, we have tackled more and more complex cases. Let's take a quick overview of 2021. We have done 17 cases of kidney transportation, 2 heart transplantation, 6 corneal, 2 livers and 6 bone marrow transplant patient. Well, as we all know, that transplantation is quaternary care by itself. But what you -- what we are doing here in Bumrungrad International Hospital is that last year in the kidney transplantation, there is one incompatible blood group payers, which means that actually the blood group of the patients and the donor is not compatible, and we need to adjust the medication and surgical technique to keep the patient and the donor and the best clinical possible. And we have also done the third transplantation, which means that the first and the second organ that was transplanted has already failed after some time. Now the patient has gone back to his and her normal lives without the need of hemodialysis. In heart transplantation, of course, it's a big deal, but one case of heart transplantation last year needs extracorporeal membrane oxygenation or what we call ECMO. Her heart has already stopped working and solely depends on the machine to survive. And without the donor heart, she is not going to live until today, which fortunately, she is now alive and well. Our sixth case of corneal transplantation eye surgery seems to be the smallest one in all transplantation. But actually, there are some certain techniques that is suitable from each patient to each patient. And we can do endothelial technique, which is suitable for one type of patient instead of doing the regular ones. This can be done only in medical schools and specialized eye center. 2 liver cases, the average age of liver transplantation cases is around 50-ish. But for last year, we have done a case with 7-ish years and has set a new record for advanced age. She is still doing well until today. And the last but not least, 6 cases of bone marrow transplantation. Bumrungrad we deal for saving lives of blood cancer or leukemia patients. And we cannot do what we have done last year with the complexity of the cases that we need to depend on our genomics team and the specialized pharmacies on oncology. And now we are going to go forward in 2022. Now we are pushing enhancement of the clinical program and strengthening our transplantation teams, all the teams, especially heart and corneal transplantation for this year, doing heat transplantation needs more than one center of excellence. Actually, it is 3. The first is our Heart Institute. The second is transplantation. And the third one is our critical care unit. And also the corneal, as we have mentioned, that is medical schools and specialized eye center standard. In 2022, we're expanding to our Bumrungrad Health network, hospital referrals. We have successful cases last year on kidney cases and now we are looking forward for more. Also, we involve third party payor. And also the international patients, of course, all the rules and the regulations are now not only a low but ease the patient to access the care they need for organ transplantation even though they are non-residents or foreigners. And our doctors and nurses team is really keen on the -- all these regulations and are willing to help the patients and the family out of way. And finally, I'm happy to announce that last year, we have done 3 cases of corneal transplantation. We have already had one heart transplanted as a total is 3 cases already. And 5 cases of kidney transplantation. We have done 17 last year. We now have 5 and 3 of which are foreigners that international payers leaving related kidney transplantation. And just this week, we have one case of bone marrow transplantation. He is still doing really well in the hospital right now. Thank you so much.

Thank you, Dr. Suwanna. Now we're going to dive a little bit more specifically into our Heart Institute, which has grown significantly over the year in terms of both service offering and in terms of its revenue contribution. So I'd like to introduce Dr. Achi to present further on the Heart Institute. Dr. Achi?

[Foreign Language]. Good morning, everyone. Good morning all dear investors. May I introduce myself? I am Dr. Achirawin Jirakamolchaisiri, the Strategic Business Unit Head and also the Director of Heart Institute Bumrungrad International. There was the paradigm shift about Cardiovascular and also the reason why Bumrungrad International changed the heart centers to become new heart institute. We are facing the aging society right now. People are getting orders even live longer, which result in the more prevalent for the NCD or non-chronic non-communicable disease. And almost half of the NCD was cardiovascular disease, it's not cancer, it's not maternal disorders, it's not liver disease, it's cardiovascular disease and composed of our cardiovascular disease, most of them almost half was the coronary artery disease, followed by the stroke or cardiovascular disease and heart failure, which we have to prepare and change ourself first to answer the unmet needs of our patients and customers. Cardiology was not comprised into just cardiology themselves or one department. If you suffer from heart disease, you may have many questions about yourself, about your families that you might want to get the answers and not just only cardiologists to answer that question. You can see this is from our real patients. He was asked all these questions after we give him the diagnosis of Brugada syndrome. So we have to change from single disciplinary to multidisciplinary. And you can see at every question they are responsible members, responsible specialties to answer these questions, whether or not I should or can I back to marathon, it should be answered by the cardiac rehabilitations and also the physiotherapist. Is it best treatment available for Brugada syndromes the questions answered by the Director of Physiologists? Will this disease inherit to my family members should be answered by the cardiogenic? Can I go back to my normal life? And what I have to do after I implant the defibrillator inside myself has to be answered by nursing and home care teams and how I can quit smoking should be answered by the pulmonologists and behavioral therapies. And doing this surgery for this particular disease it should be answered by the heart team and many more questions. The reasons and so purpose from multidisciplinary team at Bumrungrad International it's patient best interest. And we aim to be your lifetime partner, heart disease can happen at any age. You might familiar with heart disease in elderly, but actually, it can happen even you are younger, you are teenager or middle age man, middle age women can suffer from the heart disease and those who suffers from the early period of your life should be should receive much more care. So this is why we changed from heart center to heart institute. And I want to introduce our new structure for the institute and all subspecialty and service we provide. The Director of Heart Institute was Professor Dr. Koonlawee Nademanee, who is the world-famous electrophysiologist. And we offer coronary interventions, electrophysiology, structural heart, advance heart failure, cardiothoracic surgeries, congenital heart disease, even cardiogenetics and our newest service, heart transplantations. Looking back to last year 2021 clinical outcome of the Heart Institute. For cath lab, we performed 500 case of PCI and CAG combined together. Success rate of the PCI [indiscernible] was 99% compared to our benchmark, which is referenced from United States. The benchmark was at 95% for PCI mortalities and complication, we are at 0.3% compared to we are far better when comparing to the United States benchmark. For EPLAB, we perform around 175 cases. We do 100 electrophysiology service. AF ablation, we have 0 mortalities. We have complications combining together at 3% compared to United States benchmark at 4.5%. The Ventricular tachycardia which VT ablation, we have 0 mortality, we have 0 complication case. TAVI, since we opened service last 3 years ago, we have 29 cases. We have success rate maintaining at 100%. We have 0 in hospital mortality. For last year, our new products and new programs last year, we performed success to cases of heart plantations, which is we, at Bumrungrad International, we are the only one private hospitals with these capabilities and get the approval from Thai red cross societies and organ and transplant committee of Thailand to become heart transplant tenders. And we already perform our third case in January of 2022. Thank you.

Thank you, Dr. Achi. So this concludes the fourth quarter and full year analyst presentation for 2021. A strong quarter indeed. Stay tuned for a live Q&A on the 2nd of March and see you in the next quarter. Thank you.