Post on 27-Apr-2020
transcript
Infertility & IVF in the MENA Region - Opportunities and Challenges
Mansoor Ahmed – Director (MENA Region) Healthcare, Education, PPP
Colliers International MENA
Biography
Mansoor Ahmed
Director (MENA Region)
Healthcare, Education and PPP
mansoor.ahmed@colliers.comMain +971 4 453 7400 | Mobile +971 55 899 6091 P O Box 48817 | Dubai | UAE
http://www.colliers.com/en-gb/unitedarabemirates/services/healthcare
Overview – MENA Region
12
3
45
6
78
910
11
14
12
1516
17
13
Country Fertility RatePopulation
(Millions)
1 Morocco 2.5 36.0
2 Algeria 3.0 42.2
3 Tunisia 2.2 11.7
4 Libya 2.3 6.6
5 Egypt 3.4 101.1
6 Sudan 4.5 42.5
7 Lebanon 2.1 6.8
8 Syria 2.8 18.4
9 Jordan 2.8 10.1
10 Iraq 3.8 40.4
11Saudi
Arabia2.4 34.1
12 Kuwait 2.1 4.2
13 Yemen 3.9 29.5
14 Iran 2.1 82.8
15 Bahrain 2.0 1.6
16 UAE 1.4 9.6
17 Oman 2.9 5.0
18 World 2.4 7.5 Bn
➢ As defined by UNICEF, MENA is a diverse region, including 19 countries & territories from North Africa
& the Middle East. While the majority of the countries are still in a phase of medium to high fertility and
population growth, others are already at an advanced stage of demographic transition, with low to very
low fertility rates.
➢ According to UNICEF, By 2050, fertility will be below replacement level of 2.1 children in most
countries, while still 3.0 births per woman in Iraq and Yemen.
GROWING IVF MARKET
1BIVF Market Value
in MENA Region
10 – 12 BGlobal Market
Value
50%Of IVF cases cites Male
Infertility as the reason
$ 7-10,000 Average Cost of
IVF Treatment
500 m
Key healthcare indicators in the MENA Region has shown improvement
Life expectancy at birth, years
Mortality rate, infant (per 1,000 live birth)
Mortality rate, under 5 (per 1,000)
Mortality rate, adult (per 1,000 adults)
Fertility rate, total (births per woman)
2018
IND
ICA
TO
RS
Comparison
MENA region
1980
61.17 75.73
49.9 18.3
65.1 21.9
255 112
6.2 2.8
Improvement (+)
/decrease (-)
+24%
– 64%
– 67%
– 56%
– 55%
Despite falling fertility rates, the number of births in the
region will remain relatively stable until 2050 because
of the growing number of women of reproductive age
The number of under-five deaths in the region will
continue to decline over the coming decades
By 2030, half of the MENA countries will have total
fertility rates at or below replacement level
The Changing Population Composition – MENA Region
0-45-9
10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-79
80+
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
2018
484 m
2030
580 m1980
184 m
Life expectancy at birth, years
Fertility rate, total (births per woman)
1980 2018
75.7361.17
2.86.2
+24%
– 55%
The Changing Population Composition – Egypt
2018
97 m
2030
117 m
1980
43 m
0-45-9
10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-79
80+
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
Life expectancy at birth, years
Fertility rate, total (births per woman)
1980 2018
71.658.3
3.375.61
+24%
– 55%
The Changing Population Composition – Saudi Arabia
2018
33 m
2030
45 m
19809.7 m
00-04
05-09
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
00-0405-0910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7474-79
80+
00-04
10-14
20-24
30-34
40-44
50-54
60-64
70-74
80+
Life expectancy at birth, years
Fertility rate, total (births per woman)
1980 2018
74.862.8
2.47.2
+18%
– 67%
The Changing Population Composition – UAE
2018
9.0 m
2030
10.9 m
1980
1.0 m
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
Life expectancy at birth, years
Fertility rate, total (births per woman)
1980 2018
77.668.2 +14%
– 75%2.47.2
Declining Fertility in the MENA Region
Fert
ility
Rat
e (
Bir
th P
er
Wo
me
n) %
De
crease
in Fe
rtility Rate
Th
e C
hangin
g F
ert
ility
in t
he M
EN
A R
egio
n 1
960 -
2017
7.5
7.06.7
6.2
7.6
7.2
5.7
7.27.0
7.26.9
7.27.4
6.9 6.9
7.9
3.0
2.0
3.4
3.8
2.8
2.1 2.12.3
2.5
2.9
1.9
2.4
2.8
2.2
1.4
3.9
-450.0%
-400.0%
-350.0%
-300.0%
-250.0%
-200.0%
-150.0%
-100.0%
-50.0%
0.0%0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
Algeria Bahrain Egypt Iraq Jordan Kuwait Lebanon Libya Morocco Oman Qatar SaudiArabia
Syria Tunisia UAE Yemen
1960 2017 % Change
• “Ideational Change” is a key factor in MENA region choosing to limit the fertility through contraception in order to invest more time, energy and money
into the education and success of each individual child.
• Countries like Bahrain, UAE dipped below replacement fertility rate - the fertility rate required for a population to maintain itself is usually 2.1 children for
every woman.
Change in Adolescent Fertility Rate (Births Per 1,000 Women Ages 15-19)
Fert
ility
Rat
e (
Bir
th P
er
Wo
me
n) %
De
crease
in Fe
rtility Rate
Th
e C
hangin
g F
ert
ility
in t
he M
EN
A R
egio
n 1
960 -
2017
27.826.4
89.5
70.4
52.6
28.5
48.8
13.9
40.5
81.3
49.5
69.873.6
19.7
55.4
148.7
10.4 13.3
53.8
71.7
25.8
8.114.5
5.7
31.7
13.0 9.9 7.3
38.5
7.8 6.5
60.4
-900%
-800%
-700%
-600%
-500%
-400%
-300%
-200%
-100%
0%
100%0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
Algeria Bahrain Egypt Iraq Jordan Kuwait Lebanon Libya Morocco Oman Qatar SaudiArabia
Syria Tunisia UAE Yemen
1990 2017 % Change
• Healthcare in MENA Region is gaining significant traction on account of various factors including government initiatives to encourage world access to
medical treatment resulting in better healthcare opportunities and treatment.
• The healthcare in MENA is undergoing a structural shift. In order to adapt to the demands of educated & health-conscious population a effective family
planning is taking a transition.
Demand Drivers for IVF in MENA region
1
Literacy Rate
MENA region is turning page on Literacy by making
education as a key part to prepare for future. The overall
literacy rate for both men and women in the Arab World
has increased from just below 62% in 1978 to over 85%
in 2016, empowering women and this directly influences
their fertility behavior as they are included in the
household decision making, age of marriage and family
planning.
Gender Selection
Procedures like gender selection are getting more
reliable and consistent as the technology is developing.
Medical tourists from countries in which gender
selection is prohibited or individuals who wish to seek a
gender selection are willing to pay a price for it.
2
3
4
Late Marriages
Late marriage and infertility has an imperative
relationship. More and more women in the region are
focusing on building their career. Thus, delaying
marriage and putting off having a family due to work,
which is triggering infertility
5 Poor Lifestyle
Smoking, consuming too much alcohol, mental stress
and poor diet have a negative effect on both male and
female fertility. Male infertility identified as a growing
problem occurring in approximately 50% of the cases in
the GCC and Middle East, in addition to genetic
diseases.
6
Female Labor Force Participation
Overall female labor force participation rate in the Arab
World has increased from 20% in 1990 to over 22% in
2016. Most of the GCC countries made significant
improvement, such as in the UAE the ratio increased
from 32% to 42%, KSA (15% to 23%), Oman (21% to
32%), while the ratio in Egypt remains more or less
static increasing from 23% to 24%. The increase in
female participation in labor force and an aspiration for
economic freedom has a direct impact on marriage age
and fertility.
Multiple Embryo Transfer
Some countries in MENA region permits multiple
embryo transfer during any one cycle of IVF treatment
procedure resulting in twins, triplets babies. Patients
perceive a twin pregnancy as an attractive option
especially with IVF treatment being complicated and
expensive.
The problems aheadM
ain
Lifesty
le D
iseases
• Diabetes is associated with lower rates
of infertility.
• In men, diabetes can cause peripheral
neuropathies that can lead to
retrograde ejaculation and erectile
dysfunction.
• In women, there’s an association with
diabetes and insulin-related causes of
infertility like polycystic ovarian
syndrome(PCOS) and obesity. The
hyperinsulinemia associated with
PCOS and obesity can increase
functional androgen levels in women
which in turn can cause follicular arrest
(i.e. anovulation) and can adversely
affect egg quality.
Diabetes
18.5%of population
ages 20 to 79
Obesity
35.4%among adults
Hypertension
22.5%among adults
above 18 years
• In men, overweight & obese men are
more likely to have low sperm count
altering the physical and molecular
structure of the germ cells in the
testes.
• Obesity in women reduces the
chances of conception & increases a
risk of miscarriage or a pregnancy
may lead to congenital anomalies.
• Hypertension in men is linked to poor
semen quality.
• Women with Hypertension have a 25
percent higher risk of developing
preeclampsia
Cost of IVF Treatment
14
Saudi
Arabia
Spain
Czech
Republic
Russia
UK
Egypt
India
Turkey
United
Arab
Emirates
USA
IVF Cost: $ 3000 – 5000
Egg Donation: Not allowed
Sperm Donation: Not allowed
IVF Cost: $ 3000 – 5000
Egg Donation: Allowed
Sperm Donation: Allowed
IVF Cost: $ 3000 – 5000
Egg Donation: Allowed
Sperm Donation: Allowed
IVF Cost: $ 3000 – 5000
Egg Donation: Allowed
Sperm Donation: Allowed
IVF Cost: $ 7,000 – 10,000
Egg Donation: Not allowed
Sperm Donation: Not allowed
IVF Cost: $ 5,000 – 10,000
Egg Donation: Not allowed
Sperm Donation: Not allowed
IVF Cost: $ 5000 – 7,000
Egg Donation: Not Allowed
Sperm Donation: Not Allowed
IVF Cost: 5000 – 15000 $
Egg Donation: Allowed
Sperm Donation: Allowed
IVF Cost: $ 3000 - 5000
Egg Donation: Allowed
Sperm Donation: Allowed
IVF Cost: $ 3000 – 5000
Egg Donation: Allowed
Sperm Donation: Allowed
The cost of IVF treatment in UAE is most expensive in
the MENA Region followed by Saudi Arabia & Egypt. At
a high end facility in UAE the price of IVF treatment can
go up to $15,000.
Cost of IVF treatment in
MENA Region is at par
with Western Countries.
Egg & Sperm donation
is also not allowed.
THEN WHY CHOOSE
MENA?
Market Opportunities
• Most MENA countries are
experiencing rapid population growth
and providers of fertility treatments
operating in a individual or a hospital
set up lack affiliation from International
groups.
Large Population &
Lack of International
Affiliation
Egypt• Egypt’s healthcare system is improving both
quantitively and qualitatively to meet with the
existing and potential demand gap.
• Egypt has a strong reputation within the
region of having quality doctors,
infrastructure, and easier visa access when
compared to some of the regional
competitors.
Fragmented Market
• Despite increased interest and investments, the
fertility market in Middle East remains relatively
fragmented. The market is served mostly by
individual clinics and as hospitals unit.
UAE• The UAE is forecasted to command 5.5 %
of the global In-Vitro Fertilization market
by 2020.
• UAE has a strong health regulation
framework, which has helped ensure
quality healthcare, a catalyst for medical
tourism.
• Foreign investor can have a 100%
ownership.
Saudi Arabia
• In line with the government’s
Vision 2030 and the National
Transformation Program (NTP),
the Ministry of Health (MoH) is
expected to spend close to US$71
billion over five-years ending in
2020.
• Foreign investor can have a 100%
ownership.
Visa RestrictionsIn case of some MENA there is difficulty
in getting visas for the Western
Countries. Therefore, increasing the
healthcare market within the region.
Gender Selection/Family
Balancing
Shift from a Taboo to a Cultural AcceptabilityThe stigma of IVF treatment is fading and people are willingly
coming forward for fertility treatments.
Why UAE?
Most common nationalities seeking IVF treatmentin the UAE are Emiratis, GCC nationals,expatriates from sub-continent and Africa. Latelypatients have also started coming from China.
Top
Nationalities
Medical tourism accounts for 10% to 15% of the IVF patient volumes.
Medical
Tourism
The success rates in the UAE Region are quitehigh. Patients also come for gender selection, asUAE, is one of the few countries where genderselection is still permitted.
Why UAE?
Dubai being an attractive “tourism destination”offers several entertainment, cultural andshopping options which are “pull” factors formedical tourism beside quality of medial offering.
UAE: “The
Destination”
Factor
Approximately 15% to 30% parents opt for IVFtreatment to conceive second child, while 10%-15% return to IVF centres to have anothersuccessful treatment cycle to conceive theirsecond child using IVF treatment again.
The Second
Child
The reason for multiple pregnancies is due tomultiple embryos transferred. Some patientsperceive a twin pregnancy as an attractive optionespecially with IVF treatment being complicatedand expensive.
The Twin
Factor
The average cost of an IVF treatment rangesbetween USD 7,000 – 10,000, but it may varydepending upon the type of treatmentrecommended for each patient including the costof medications, stimulation protocols, proceduralcharges, blood tests e etc.
The IVF
Treatment
Cost
The key challenge is restriction on embryofreezing which results in repeat cycles of fulltreatment thereby increasing patients’ costs andmorbidity.
Key
Challenges
Major key challenge is a separate licensingrequirements across the different regions. Asingle, unified, licensing process can resolve thischallenge. Some MENA Countries still don’t allowembryo freezing whereas UAE recently brought areform by allowing embryo freezing in the region.
Regulatory
Challenges
In over 50% cases male infertility is the reason forseeking IVF treatment. The factors contributing tomale infertility include lifestyle, diabetes, obesity,hypertension and genetics.
Male
Infertility
Key Insights for Investors
Revenue Streams
Typical Charges for IVF in the region are:
• UAE: USD 10,000 to 15,000 per cycle
• KSA: USD 7,000 to 10,000 per cycle
• Egypt: USD 5,000 to 7,000 per cycle
Volume of patients
On average, a team comprising of a physician
(Fertility Consultant or Specialist), 2
embryologists and up to 4 nurses can manage
300-350 IVF cycles annually. Most clinics in the
region typically comprise of 2 to 4 such teams.
Set-up costs
Typical set-up cost of a mid-size premium facility
ranges from USD 2.5 million to USD 3.5 million
inclusive of medical equipment, furniture and fit-
outs but exclusive of premises construction.
Financial returns
The business offers attractive returns for
investors in the region. EBITDA margins for
efficiently run clinics at optimal capacity typically
range between 25% to 40%. Project investment
returns (IRR) typically ranges from 18% to 25%.
Case Study:
A successful premium IVF center in UAE
About the Facility
Services
Patient Profile
Key Reasons of
Infertility
The idea of IVF facility was conceived in 2009, and
the facility commenced operations in Q1 2011.
The facility performs annually:• IVF/ICSI: +3200
• IUI: +150
• Cryopreservation:
+2000
• Reproductive
Surgeries: +200
• Sperm extraction: +120
• Genetic testing: +550
• Age Group: 40% patients are aged less than 35
years, whereas 60% are aged over 35 years
• Payer group: 70% insured, 30% self pay
• Nationality: 64% Emiratis, 16% Middle Eastern,
8% Africans, 5% Asians, 2% Westerners, and
5% Other Nationalities
Most patients present with primary Infertility.
Tubal Factor – 0.3%, Ovulatory Dysfunction –
1.5%, Diminished Ovarian reserve – 0.0%,
Endometriosis – 0.1%, Uterine Factor - 1.2%,
Oligospermia – 17.9%, Male factor - 11.6%,
Other Factor - 5.2%, Unspecified - 61.1%
About Colliers’ International
Dubai
Abu Dhabi
Riyadh
Jeddah
Cairo
Regional
5Regional Offices
Over 20years
Regional and
Management
Experience
90+
Professionals
15Professionals
dedicated Healthcare,
Education & PPP team
Global
$ 3.3 BN
IN REVENUE
$127 BNTransaction Value
68COUNTRIES
6CONTINENTS
17,000PROFESSIONALS
About Colliers’ Healthcare & Wellness Advisory Services
Services Offered
• Strategic & Business Planning
• Economic Impact Studies
• Medical Planning
• Market & Competitive Studies
• Catchment Area Analysis
• Market & Financial Feasibility Studies
• Financial and Business Modelling
• Market & Commercial Due Diligence
• Land & Property Valuation
• Business & Brand Valuation
• Mergers & Acquisitions Assistance
• Buy Side Advisory / Sell Side Advisory
• Sale & Lease Back Advisory
• Public Private Partnership (PPP) & Privatisation
• Operator Search & Selection and Contract Negotiation
• Site Selection & Land / Property Acquisition
• Asset & Performance Management
• Performance Management & Industry Benchmark Surveys
Why Colliers
A Truly Regional Team with International
Experience
Colliers Advantage
Market Awareness
Creative Solutions
Offer a memorable experience
Access to Subject Matter Experts
Qualified and Experienced Staff (15)
Shared Knowledge
The Knowledge Hub
To download https://www2.colliers.com/en-AE/Services/Healthcare-Services