IHH Healthcare Berhad (IHH) Earnings Call Transcript & Summary

Good morning, everyone, and welcome to IHH Healthcare Berhad Q1 '25 Results Briefing. Thank you for taking the time to join us today. My name is Kelvin Chong. I'm from the Investor Relations team. With me today, I have Dr. Prem Kumar Nair, Group CEO; Mr. Dilip Kadambi, Group CFO; and Mr. Ashok Pandit, our Chief Corporate Officer. Warm welcome to all. For today's session, we will begin with Dr. Prem sharing the group's strategic priorities for the year ahead, followed by Dilip giving us the key financial highlights. And then we'll turn the floor over to Ashok, who will take us through the key operational highlights for each country. Dr. Prem will then conclude with key takeaways, and we will then proceed to the Q&A session. With that, I'll turn the floor over to Dr. Prem. Mr. Prem, please.

Thank you, Kelvin, for the introduction. A very good morning to all of you. Thank you for joining our Q1 2025 results briefing. Today, we will begin with our transformation journey, followed by a review of our Q1 2025 financial and operational performance. Last year, we embarked on our 5 strategic growth priorities underpinned by our ACE framework. These priorities comprise growing organically, expanding across the health care continuum, developing new growth engines, capturing inorganic opportunities and turning around underperforming assets. In order to future proof ourselves and accelerate the growth of these strategic priorities in a capital-efficient manner, we have initiated a comprehensive multiyear transformation plan along these 7 focus areas. As one of the largest health care groups in the world, we are already recognized for our high standards of clinical excellence, and we are committed to building upon this strong foundation to deliver even better outcomes for our patients. We are actively implementing new care models, such as our out-of-hospital strategy, which is already underway in Singapore and Hong Kong, which involves shifting lower-equity patients to nearby ambulatory care centers, transitional care facilities and even home care. Beyond this, we are exploring future care models across all our geographies to continuously innovate how we deliver care and enhance the patient experience. Through operational excellence, we look to improve operational and cost efficiencies. For example, our new operations command center in Malaysia offers a realtime comprehensive overview of each hospital's operational metrics. This allows us to proactively manage critical resources. In today's data-driven world, health care is also leveraging information to yield better outcomes while we align our IT platform across all our geographies. So here are some examples within our tech, data and digital transformation road map. Cerebral Plus, or C+ in short, houses our hospital information systems and electronic medical records. We've also implemented the outpatient EMR in Fortis Healthcare and will complete the EMR implementation in Singapore later this year. The Operations Command Centre, where you can see this picture, this provides real-time insights, enhances patient experience and provides better cost control as well as transparent billing, offering a more seamless experience overall. We have also embarked on an AI initiative to free up valuable nurses' time away from administrative tasks and more into clinical care. And we have employed AI imaging applications in Malaysia, Singapore and North Asia while evaluating for other uses in AI. As I have consistently pointed out, IHH operates one of the most risk-diversified health care platforms. And this quarter is a clear demonstration of that. Even with several macroeconomic and geopolitical factors affecting operations in some geographies, our group maintained a strong, resilient performance. Our diversified platform across multiple geographies ensures we always have areas that outperform, enabling us to mitigate risks from another geography. The U.S. tariffs has further fueled global uncertainties and volatilities across markets, including currencies, which has impacted our reported results in ringgit from a translation perspective, as you will see from our reported versus constant currency numbers. We also saw increased payer pressure across markets. And finally, the full Ramadan effect was captured in Q1 as compared to being spread across 2 quarters last year, and this impacted our core markets of Malaysia, Singapore and Türkiye. We have achieved robust revenue growth despite a challenging macroeconomic environment, driven by an increase in inpatient admissions and higher revenue intensity across core markets. Our performance was even stronger on a constant currency basis, clearly demonstrating how our diversified portfolio strategy enhances IHH's resilience. EBITDA and PATMI margins remained stable despite one-off events such as Mount Elizabeth Hospital's renovation. We continue to increase bed capacity through the opening of Acibadem Kartal in Türkiye in mid-February 2025 and the acquiring of the 228-bedded Shrimann Hospital -- Superspeciality Hospital in India, which we expect to complete during the year. On the clinical leadership front, we are constantly expanding and improving on our care offerings to patients. Recently, Gleneagles Hong Kong became the first private hospital in Asia to offer the histotripsy treatment, which enables doctors to eliminate tumors without any incision, radiation or needle. We believe that some of these events will work out in the first half of 2025, and we are positive about the prospects and outlook in the second half of the year. With that, I'll pass the time over to Dilip, our CFO, to cover the financial highlights. Dilip, please.

Thank you, Dr. Prem, for the overview. As Dr. Prem has already mentioned, our diversified platform across multi-geographies ensure that we always have areas that outperform, enabling us to mitigate risk from other geographies, allowing the group to maintain a strong, resilient financial performance. As always, we will focus on the blue box, which more accurately represents our operating performance. Despite several headwinds, such as the U.S. tariffs, the FX volatility, payer pressure and the full effect of Ramadan holidays in Q1 this year versus being spread across Q1 and Q2 of last year, the company still achieved a 7% growth on revenue. On a constant currency basis, we had a robust growth of 17% on revenue and 8% on EBITDA, demonstrating strong operational performance across all our key markets. I would also like to mention a few one-off factors impacting this quarter, namely the Mount Elizabeth Hospital, which is currently running at half the capacity, as mentioned to you previously. And we expect the full reopening of Mount E Orchard by Q3 of this year. Our 2024 reported PATMI base is high due to the one-off Turkish tax credit -- deferred tax credit that we received last year but was absent this year. We had an asset impairment in Fortis and also a full quarter of interest costs for the Island Hospital acquisition that we did late last year. As we ramp up the Mount E Orchard and we sign up deals with payers, we expect the second half of this year to exhibit stronger performance. We are also actively paring down our debt from the free cash flow that our business generates actively. Similar to previous quarters, we have in the blue box the reported revenue and EBITDA. And next to it are the respective metrics on a constant currency basis, i.e., stripping out the translation impact. Overall, the group achieved a 17% revenue growth and an 8% EBITDA growth on a constant currency basis, demonstrating robust financial performance. Malaysia demonstrated robust financial performance, building on the acquisition of Island in Q4 of 2024. Singapore revenues on a constant currency basis was higher despite Mount E Orchard operating at half the capacity for entire Q1 2025. This closure impacted EBITDA and margins in line with our guidance that we mentioned in Q4 of 2024, and we expect the ramp-up to come back in Q3 and Q4 of 2025. Turkey and Europe demonstrated revenue and EBITDA growth on a constant currency basis despite having the full impact of Ramadan. EBITDA was marginally impacted by the one-off start-up costs of 2 new hospitals, namely Kartal and Vitosha. India continues on its growth trajectory with double-digit revenue and EBITDA growth on a constant currency basis. Fortis is acquiring the 228-bed Shrimann Superspeciality Hospital in Punjab, which we expect to complete later this year, and also opened the 350-bed Manesar hospital. Overall, we've seen strong operational performance across all our key markets, which will continue to build. And as we continue to reopen Mount Elizabeth, we believe the Q3 and Q4 of this year will be fairly robust. This slide shows our financial performance trends on a quarterly basis. The solid purple line shows our EBITDA margins ex MFRS. In Q1, it was 22%, within our guidance range of 22% to 24%. We will see Q1 is an anomaly given the macroeconomic headwinds. While Q2 continued to be soft, we anticipate a reasonable rebound in the second half of the year. This recovery will be driven by successful negotiation with payers and completion of Mount Elizabeth Hospital renovations. Next, our core PATMI, which excludes EI and MFRS, is represented in the bold green line. It stood at 8% in Q1. Excluding the Island financing cost, it was very close to what it was last year. Looking ahead, we still maintain our EBITDA margins to be somewhere between 22% to 24% and our PATMI, ex EI, ex MFRS, within the range of 8% to 10%. This slide shows our business has a very strong operating cash flow for Q1. Our strong cash generation and healthy cash balances allow us to fund CapEx, the investing activity as well as paying down of our debt. And this concludes our financial section. With this, I would like to hand over the floor to Ashok.

Thank you, Dilip. Let's start with our 5-year growth plan. Q1 2025 performance occupancy stood at 69%. Inpatient admissions across the group were up 4%, and lab tests were up 5%. In 2024, we've added 1,000 new beds, and we are on track on the 4,000-bed capacity that we have announced earlier as part of our 5-year growth plan. Fundamentally, expansion continues to be strong across our markets, mainly driven through brownfield expansions. If we go to the next slide. Let's start with Malaysia. Malaysia saw a few things. One was the impact of holidays, essentially Ramadan and CNY all in the first quarter. And there is also some impact in terms of headwinds from medical inflation. Given our acquisition of Island Hospital, we were still able to show robust increase in inpatient admissions, up 6%. Revenue intensity was also up 6%, giving us a revenue growth of 17% and EBITDA growth of 14%. We were able to maintain our EBITDA margins at the 24% sort of levels. I think we are pleased to share that we are almost at the tail end of negotiations with the payers and hopefully strike new deals with the payers. We do expect to see a robust set of numbers as we go into Q3 and Q4 of the year. As mentioned earlier by Dr. Prem, as part of our transformation journey, we are also actively managing our key costs, which are largely manpower, and we're trying -- and focus on optimizing variable costs from a procurement point of view. The Island acquisition remains -- and integration remains on track with synergies extraction from the transaction. If we go to Singapore. As you can see, while there was some impact in terms of 50% bed capacity because of closure of Mount Elizabeth Hospital, our inpatient revenue grew by a healthy 10%. Admissions are impacted largely by the closure of beds at Mount Elizabeth Hospital, thereby impacting revenue to a slight extent. We do believe that this capacity will pick up during the course of the year. Like Malaysia, Singapore also has some impact from payer pressure. And therefore, our focus remains on cost optimization. We are collaborating with insurers to offer targeted packages for both foreign and local patients in the market. If we go to our next key market, which is Türkiye in Europe. While there was some impact of holidays similar to Malaysia in Türkiye as well, we did see a very positive impact in terms of revenue growth, which was 12% driven by revenue. IP revenue per patient had been going up by 16%. Our EBITDA margin was partly impacted, as mentioned by Dilip earlier, which was driven by pre-op cost of Kartal and Vitosha. In terms of constant currency basis, our revenue and EBITDA growth are very healthy 33% and 15% in the market despite the impact of Ramadan in Q1 2025. We also -- we continue to see better revenue intensity given -- from more acute patient mix in the market. If you look through our non-lira contribution, this remains quite stable. In Turkey, the foreign patient revenue grew by 13%. And in Europe, the European operation grew by 24%. Despite FX volatility and translation effects, our Turkey and European operations have done well and continue to see significant improvement and contribution to the group. We remain confident on the outlook for these markets as we go into the next -- second half of 2025. Moving on to India. We saw slightly higher revenue driven by higher inpatient volumes, also by positive inpatient and revenue admit growing by 4%. We saw a closer partnership between Fortis and Gleneagles India, something that we have highlighted to everyone over the last few quarters. As mentioned by Dr. Prem and Dilip earlier, we are -- we've done a 228-bed acquisition of Shrimann Superspeciality Hospital in Punjab and also opened the 350-bedded hospital in Manesar. Fortis recently announced results. The results remain quite healthy, and the overall outlook for the sector remains quite robust in the Indian markets. In terms of Hong Kong, we saw a strong Q1, healthy growth and improved profitability. Inpatient revenue per admit grew by a healthy 19%, driving the revenues by 13%. EBITDA grew by 34%, and EBITDA margin now stands at 17%. I think showing a good, strong improvement over 2024. Our laboratory continue to do well. Our business remains stable. Some impact of the holidays and hospital volumes, especially in Malaysia and Türkiye, having some impact on the top line. Revenue was down marginally by 3%. We continue to see higher volume of hybrid tests, and that remains the biggest focus for our labs across our core markets. And we continue to partner with other players as we look to rolling out newer tests in the second half of the year. To highlight a few milestones within the group in quarter 1, Dr. Prem mentioned about the command center in Malaysia. That is quite a big milestone. Other things to highlight, if you go to the next slide, was the opening of Acibadem Kartal and also a new laboratory in Mount Elizabeth Hospital in Singapore. A quick overview of our sustainability journey. We remain quite focused on our sustainability journey. Some highlights. If we look through our value-based care, our VDO track quality indicators increased from 113 to 202. People pillar, 49% of women on our leadership positions across IHH. Our emissions intensity per bed per day dropped by 3.2% across all our operations. In recognition of our sustainability efforts, we are now included in the FTSE4Good Bursa Malaysia and FTSE4Good Bursa Malaysia Sharia Indices. And we also secured our first $300 million sustainability-linked loan. With that, I'm going to hand over to Dr. Prem.

Thank you, Ashok. So just to recap before we move on to the Q&A section, I would say that despite the challenging macroeconomic environment, our diversified operations has shown resilience and even grew on a constant currency basis. We will continue to increase bed capacity and improve our clinical offerings. Also, we are embarking on a multiyear transformation project that I mentioned earlier, and these are in 7 focus areas that will accelerate the growth of our strategic priorities and future proof the business. Despite potential global and regional economic challenges, we are committed to providing our patients with excellent clinical offerings and care. At the same time, we are also positive about the outlook and prospects on second half of the year after some of these issues are worked through in the first half. We will also drive profitability through prudent capital management to ensure a healthy ROE for all our shareholders. Thank you very much. I will now hand over the call to Kelvin for the Q&A. Thank you.

Thank you, Dr. Prem, Dilip and Ashok, for the insights and updates. Given the large number of participants on the call, if I can kindly request participants to limit themselves to 2 questions. And if there are additional questions, you may wish to rejoin the queue. We can start the Q&A session. [ Yen ]?

I have 2 questions here. The first is on Malaysia. So could you share the revenue and EBITDA contribution from Island and Timberland this quarter, please? I'd just like to know organically, what's the revenue growth number there? Secondly, on Acibadem, could you give us an update on the ground and the patient volumes?

Sure. [ Yen ], thank you for the question. In terms of our overall growth for Malaysia, as I can -- as you know, that Island has always been part of the strategy. Medical tourism is something that we have identified as a core growth area, and the action to actually acquire Island was quite deliberate. So the revenue growth you see does include Island. And without Island, I would say the revenue growth was probably flattish, a slight increase but flattish. And again, bear in mind that, as Dr. Prem mentioned, in Q1 of this year, we had a full impact of Ramadan versus last year where Ramadan spilled over almost, I think, 9 to 10 days in Q2 as well. So that's on Ramadan. On Turkey itself, we did see -- as you can see from Turkey, we did see a strong growth on revenue. And if you look at overall volume as well, we did see the volume go up despite Ramadan. And the more interesting thing here is if you look at the IP revenue per IP admit, we saw a pretty strong uptick in Turkey.

Thank you, Dilip. Next, [ Jun So ].

I have 2 questions from my end. Can management share if your hospital in Malaysia were being delist by any of the insurer for assets towards the guarantee letter features. My follow-up question would be your EBITDA margin, especially on your Malaysia segment. We do see some sort of drop in this quarter that you mentioned, which was due to the measure to address medical inflation. Can you elaborate more on what are those elements?

Okay. So maybe I'll start by describing the situation in Malaysia now. From the peak of payer issues last year, primarily due to the high inflation in Malaysia, things have abated somewhat. The ringgit has strengthened. Imported inflation has come down. And many of the issues that triggered this issue have abated significantly. You'll notice that many things have gone off the front pages of the press because we have now been negotiating directly with the insurers. As part of negotiations, we are offering more packages. We are offering bundles and some discounts as well if the insurers continue to use our hospitals on a cashless basis. Almost all our hospitals are still within the cashless system. So my prognosis for Malaysia is that things have improved considerably. The DRG issue, as you know, has also abated. So while there will be some softening of the admits and the revenues because of these measures, but I think it just means that now we work better with the payers and with all parties, right, that are very relevant to this payer-provider issues.

Thanks. And I think there was a second question around the Malaysia margins and efforts to tackle these measures. Before Dilip expands on that, I'd just like to reiterate that the Malaysia margins, while we have included a 1% compression, it is still within expectation and in line with our guidance. Dilip can share some of the measures.

Sure. So even though you see a small compression in margin, we do believe that -- as I've always guided all of you, we think the Malaysia margin should stabilize in the order of somewhere between 24% to 25% on a steady-state basis. So as Kelvin mentioned and as Ashok mentioned previously, we are working on several initiatives on the cost side as well to ensure that we curb medical inflation.

Thank you. Next, Wee Kuang.

Can you hear me?

Yes.

All right. I think on the [indiscernible] check, I mean [indiscernible].

Sorry, Wee Kuang, your voice is breaking up.

Can you hear me now?

Yes, still choppy on your end.

Just give me a moment. I'll get back in the queue. I'll come back after the next question.

It's okay now.

Okay. Okay. Good. So I'd just like check how we are managing the capacity within Mount E Orchard, especially among doctors and patients. Do we already have the staffing required to support the full reopening in the second half? And secondly, I think I just wanted to get an update in Turkey and Europe. I think just mainly in Turkey, I think we understand that there's kind of a small kind of earthquake in April. Just wondering if we have seen any impacts to patient volumes on the ground during the start of second quarter.

Okay. On Mount E Orchard, it was fully staffed and the renovation started. As certain areas were affected like the wards and some of the outpatient areas, we did redeploy staff to our other 3 hospitals in Singapore. So we did not let the staff go because it's very, very difficult to get back our staff, especially those in the ICU, the OTs and some specialized areas. And now as Mount E ramps up in the second half, the staff will come back to Mount Elizabeth Hospital, and the wards and various areas are opened up. So we will be fully staffed. Singapore for the last few years has been well resourced in terms of manpower, and it continues to be. So no worries at the Mount Elizabeth end. The earthquake in Turkey did not affect our operations at all. We monitor it quite closely. We got reports from our Turkish colleagues, but there was no impact to our operations.

Thank you, Dr. Prem. Next, we have Neha.

My first question is on the Turkey business. Dilip, I think you mentioned that there was an impact from the opening of Kartal and Vitosha during the quarter. How should I understand about when we start seeing profitability from new units in Turkey? Because I understand the turnaround time or the ramp-up time there is very different from what we usually should see in new hospitals. That's my first question. How long would that continue? And second, in terms of Malaysia, these efforts that we are taking to address medical inflation, when do they start actually generating returns for us in terms of us going back to normalized level of occupancy and profitability? Is this a couple of quarters before it sort of cycles now? Or it's just a onetime impact that we saw in the quarter?

Sure. So in terms of the hospital opening, Neha, as you rightly pointed out, we opened the Kartal Hospital in Istanbul itself. And as you rightly pointed out, in Turkey, the ramp-up is quite fast. We typically look at breakeven in Turkey within the first year itself. So I do expect the ramp-up to be quite fast. And some of the expenses that really that we saw was more on the pre-operating side. We have to take some expenses that hit our quarter on the pre-operating side. But we do expect the hospital to ramp up quite quickly, as you've always seen in Turkey. And on Malaysia, Dr. Prem will talk about medical inflation.

Yes. So again, I want to reiterate that the -- and you can see it. I'm sure you can observe it from the reports. The medical inflation issue is abating. It has not fully gone away, but we have all now come to the table. We had -- IHH in particular is negotiating directly with insurers and working out how we can enhance their current offerings to patients. There is also a lot of discussion on a group basis with the Ministry of Finance, Ministry of Health, with various parties, APHM, the hospital group, Life Insurance Association. So I do believe that these issues will improve and probably stabilize over the course of the year.

Thanks, Dr. Prem, Dilip and Neha. There's a couple of online questions. Perhaps I'll read it out for the benefit of everyone else. Can you comment on the news of your bidding for [indiscernible] hospital? What's the attraction and scale there. Ashok?

Yes. I think we continue to look at multiple opportunities in our markets. From M&A, we -- I've got no specific comment on this particular opportunity. But I think like we mentioned to everyone in the past, that any acquisition that we look at must have a good strategic fit. It must provide us with the right returns from an ROE point of view. We typically look at second, third year of the acquisition being accretive. And third, we remain quite disciplined in our M&A strategies.

Thank you, Ashok. There's 2 more questions from [indiscernible] posted online. Last time, we guided towards Hong Kong being PATMI positive in early 2025. Does it happen? If you no, why? Kindly elaborate measures to address medical inflation in Malaysia that is bringing down EBITDA margin. Will these measures bring down EBITDA margin further in future quarters? I think for the first question, we guided towards PATMI positive in 2025. If you look at the slides, the Hong Kong operations are doing well. EBITDA has increased 34% quarter-on-quarter. Revenue and inpatient intensity as well has gone up. So we remain optimistic and hopeful that Hong Kong will deliver this year. Second question, in terms of medical inflation measures, I think Dr. Prem, Dilip and even Ashok has touched on this. But I just wish to reiterate that will these measures bring our EBITDA margin further in future quarters? As mentioned, we are at the tail end of negotiations with payers. Again, we are hopeful and optimistic that we will remain within an EBITDA margin guidance, as mentioned by Dilip. There's Raghavendra.

Can you hear me?

Yes.

Yes.

Two questions very quickly. Firstly, now that you've completed 1 full quarter with Island Hospital, just wanted to understand if there's any change to your time line for breakeven that you are expecting from this acquisition. Is it still over 2 years, still by the end of the second year, which is 2026? Or do you think there can be some acceleration to the breakeven target? Secondly, for Turkish foreign patient share, we've seen that declining post-COVID from about over 20% in 2022 to now about 13% in first quarter. I understand there is some issues around the Ramadan period, but do you see this by this year or even next year going back to the high teens, low 20% level?

Sure. So on the Island Hospital integration, we committed to the acquisition being ROE accretive by end of year 2. I think we are still on track. As Ashok mentioned, we are still on track to kind of achieve that. In terms of some of the synergy values that we had mentioned to you, we are on track to realizing those synergy values as well as part of the Island acquisition. And with regards to your question on Turkey, mainly what we did see is the local volumes go up. So the local volumes went up far ahead of our expectations. And as a percentage of, which the foreign volume or foreign percentage revenue came down. Having said that, we expect again -- again, as you rightly pointed out, we had Ramadan effect as well. We do expect, as usual, for Turkey to go back to its high teens in the following quarter.

I think to just add to what Dilip said, I think Island strategically has been a very good transaction for us. We remain on track. But one of the biggest positives has been a large number of patients in Island are medical tourism patients. And that's a sector that has not been impacted by the other issues impacting the local business. So strategically, it's been a good -- it's been a very good asset acquisition by the group.

Thanks, Dilip and Ashok. Next, we have Karthik.

Am I audible?

Yes, you are.

Okay. Great. Just 2 questions from my side. Firstly, as far as Turkey is concerned, this 13% foreign patients mix, what are the destinations or the countries which have actually seen a decline in volumes in absolute terms? I know percentages is also impacted by the rise in local patients. But if I were to look at it in absolute patient volumes, have there been any countries or destinations which saw decline year-on-year? If so, which ones would they be?

Sure. Thanks, Karthik, for the question. So if you look at foreign patients, actually, interestingly, if you look at Turkey specifically, Turkey actually, when compared to the -- what you call the last quarter on a quarter-to-date basis, we actually saw the foreign patient share or the volume being a bit flat, which means it did not grow but it did not shrink either. And as I mentioned, the percentage of revenue contribution from local was stronger. And hence, we really saw the change in mix. Overall, I think the usual geographies that you see in terms of the Balkans, some of the Middle Eastern countries, even Eastern Europe, we saw tourist inflow pretty strong from all the typical countries that we've highlighted so far. So there's not been one single country that's fallen off, but we have been seeing inflows from all the usual suspects.

Got it. My next question is basically on Malaysia. Now Dr. Prem in his opening remarks alluded to when you talked about the sum of measures that they are taking for margin sustenance, one was actually procurement and how we were kind of working on that. So this has been a strategy that we have been working on for quite some time. So at what point of time do you think we will expect to see kind of tangible results? And where are we in that centralized procurement journey, at least for Malaysia? Any granularity that you can share will be very useful.

So I can -- you're absolutely right, Karthik. We've started the procurement journey in early 2021. As you know, in a hospital setting, if you look at the number of SKUs, each hospital has -- from an item master perspective, it's probably in the order of 25,000 to 30,000 items that you use on a daily basis. So we started off on the top. Basically, we started off with capital equipment. Over the last few years, I can tell you that whether it is a capital equipment purchase or whether it is service and maintenance contracts with all these large capital equipment manufacturers, have all been centralized at a group level, and we have full visibility in terms of these contracts. And over the last, I would say, few years, we've almost saved over USD 150 million on some of these purchases. We've also centralized in the country. We've centralized the pharmacy purchase as well as some of the consumable purchase. But I think, as Dr. Prem mentioned, there's further opportunity for us to dive deeper in some of these long-tail items, which is what we're currently doing at the country level to try and provide for the packages that you're providing to insurers, which means shifting some of the pharma into generics, branded generics, as well as looking at good alternative consumables that we can use in our hospitals.

Got it. Just one more follow-up, Dilip, I may, quickly on India. So if I look at India, right, so this quarter, our margins have been by and large flat. And we know that -- I think Fortis had a much better margin performance. So that would imply that the India operations ex Fortis probably saw some pressure. Could you just talk us through what are the areas that you're actually seeing margin pressure? And how long do you expect them to last?

Yes, I think, Karthik, to give some more color on this, I think you're absolutely right. I think Fortis saw a robust quarter. We've seen some softness in our Gleneagles operations. And I think, as we mentioned earlier, this step -- there are multiple ways we are trying to tackle. One is essentially through the transformation program. We are focused on finding some areas even in India to optimize cost. The second is we are going to go towards a close of partnership between Fortis and Gleneagles to optimize the 2 platforms we have in the market. The trend in India, if you notice, is that the larger hospitals are basically consolidating. And they're able to grow the margins. The smaller hospitals have been under pressure, largely because that's where the talent in terms of clinicians, et cetera, is moving.

Thank you, Karthik. Thank you, Ashok and Dilip. There's a question online. Could the management share a bit more on the criteria for new acquisitions? I think Dilip has touched on this quite a few times. And the criteria is that it must be EPS accretive year 2, latest year 3, must be additive to the network in filling of clusters or something that we are already in. And the third and most importantly, it must be a good asset. It cannot be something that we need to spend extensive amounts of CapEx after acquiring. Next, we'll turn over to Joe.

Okay. Can you hear me now?

Yes, loud and clear.

I wanted a bit more granularity and clarity on India, both on the longer-term and short-term perspective. What are you seeing in terms of trends over the next few quarters in terms of revenue and margins? And on the longer-term M&A potential to expand your hospital portfolio, perhaps not very small incremental way but much larger push because I think that's a market that's still quite positive and quite encouraging in terms of longer-term growth. I do also know you have legal proceedings overriding whole business, and I expect your limit on what you can say, but how has it affected the way you plan long term and also in terms of short-term operations?

So Joe, thanks for the question. I think if we look through one of my initial slides where we showed a growth plan of 4,000 beds, a very large part of that is coming via India. I think we continue to see India as a market with good strong growth potential in the medium to long term. So I think our focus remains. We are quite focused on that market. Obviously, from a growth point of view, we are going to be pushing brownfield expansion, greenfield expansion quite extensively and then look at any M&A that comes through in a more opportunistic manner. I don't have any comments on your questions around small or large. We look at each opportunity as is to see whether there is a good strategic fit to us. We remain very patient in the market. We are here. We have invested in India in the long term. So we will continue to grow in a disciplined manner in the country.

Thank you. Next, we have Wee Kuang.

Can you hear me?

Yes, loud and clear.

I just wanted to get a little bit of visibility into Malaysian operating expenses. Just trying to understand a little bit more about how much of this is fixed against variable cost and whether we have some form of flexible staffing because I do see that IHH Malaysia has been able to defend the margins even though seasonality volumes have been coming off. Yes.

Yes. So thanks for the question. But look, I think you're absolutely right. We try and variabilize most of our costs. And while doing that, as Dr. Prem highlighted, we also look at medical inflation quite seriously and look at packages. And we are signing up with various payers on packages to ensure that we contribute in a positive manner to control medical inflation. So as part of that, variabilizing some of our cost is the key. And we continue to do that, and that's why I'm reasonably confident that as we go through the year, we will still be able to kind of maintain the margin while we focus on some of these initiatives internally.

If I can just add on this payer-provider issues. I know we are talking a lot about Malaysia. But payer-provider issues have been with us in health care for the longest time, right? 20, 30, yes, honestly. And it will never go away because there is a third party paying for a patient's bill, right? So there will always be contentious issues. We've had these issues in India a long time ago, and you will notice that India is very heavily into price caps, fees controlled. Fortis, for example, has got 300 over packages, right, that's provided to various types of insurers that we have there. And yet we do very well because it's our business to manage payer issues prudently. In Singapore, we've also had this many years ago. The government formed a committee for all of us payer, providers, regulators to meet discuss. And we have managed issues very well. And you'll see that Singapore is doing very well defending its margins as well. Likewise now in Malaysia. So we take learnings that we have from different countries. Now we bring it into Malaysia. It was very heated last year. And you will find, really, if you were to look at the scene now, it has also come down, right? So -- and I can guarantee that it will come up again in another country, and we'll have to use the same playbook to manage these issues as well. So dealing with payer issues is fundamental to our business, right, and we will have to deal with it.

Thank you, Dr. Prem and Dilip. There's one more question online. For Malaysia, stripping out Island contribution, how did revenue and EBITDA change? I think Dilip and Dr. Prem and Ashok did touch on this. It will be flat, and this shows with the benefit of hindsight that it has been a good addition to the Malaysian portfolio.

And just to add, I think it's been flat despite the Ramadan effect, right? Because in 2024, we had almost 10 days of Ramadan in April as well, spillover in April as well, whereas in Q1 of '25, we had the full impact.

Thanks, Dilip. If there are no more questions -- Andy?

Can you hear me?

Yes, we can.

Just one question with respect to the growth priorities. The last growth priority has actually indicated to elevate performance of underutilized assets. Just wanted to understand. Maybe you can give us some color with respect to this. what do you mean in terms of like -- do you mean that you would like to drive efficiency? Or are there any assets that you think are not performing up to par that you can drive? Any color on that would help in terms of this.

Okay. This pillar in particular refers to China. While we do have some assets in various countries, hospitals or clinics where the performance needs to be improved, that's part of the operational work that needs to be done by the countries. But this pillar in particular refers to China, which we have mentioned in the past as well. When we took over, we had to take a good hard look at our China operations to decide do we stay, do we leave. But we opted to stay and rationalize. And that's what we've been doing for the last 2 years. We have 2 sets of operations in China. We have a group of clinics in Shanghai, and we have a hospital in Shanghai as well, right? The clinics, we have spent a lot of effort in the last 2 years. We have reorganized the leadership. Currently, our Hong Kong CEO, Dr. Kenneth Tsang, is the regional CEO for the whole of Greater China, North Asia. So he covers both Hong Kong and Shanghai. And that has yielded a lot of dividends because there is a lot of collaboration currently now in the Greater Bay area. So we've closed some clinics. We have improved the performance of some clinics, and in fact, we are confident enough to open a pretty large ambulatory care center in Shanghai Plaza. Work is now undergoing and we'll be opening in the fourth quarter. As far as the hospital is concerned, there are -- we are working very closely with the government because the government does outsource patients to private hospitals their public insurance program. So the hospital is also improving as well. So that's what the pillar refers to. It refers specifically to China, and it is improving.

Thanks, Dr. Prem. We have time for one last question. [ Selviana ]?

Sorry, I think that was excellent, sorry.

No worries. There's one more. Amanda?

Just one question for me. Just want to dive a bit deeper into the Malaysian margins. Are you able to break down the EBITDA margins between Island as well as your Malaysian hospitals given that Island generally has a higher share of foreign patients?

So look, Amanda, as you rightly pointed out, Island maintained its margin because their reliance on local payers are lesser. And they continue to maintain their margin because over 60% of the revenue of Island is from medical tourists coming into Penang. So the profile of the hospital is more akin to something like Gleneagles Penang. So it's a bit different versus the overall Malaysian hospitals. So there is a difference, to answer in short, between Island and rest of Malaysia.

Thanks, Amanda and Dilip. If there are no further questions, that concludes our analyst briefing today. Thank you all for your time. And as always, if there's any questions, please feel free to direct to myself or Joshua and Investor Relations team. Thank you all for your time. We'll see you next time.

Thank you.

Thank you.

Thank you.