Overview of PPP Opportunities and Projects for

Investment and PPP Department 2020 On Jan 4th 2019 the 50 year charter was announced by HH Shk. Mohammed bin Rashid Al Maktoum The Vice President and Prime Minister of the UAE, and ruler of Dubai

Article 5: A Doctor to Every Citizen We aim to provide citizens with medical consultations 247/ through hundreds of thousands of doctors, specialists and medical consultants across the globe. This will be facilitated by smart government application. Our goal is to transform the medical system to bring doctors closer to individuals, enhance awareness, and utilize top medical minds globally to serve the health of our citizens.

2 Dubai is a vibrant city of opportunity for professionals, investors and entrepreneurs

The Dubai Advantage THE GATEWAY THE CITY Strategic location Open economy Over 200 Nationalities THE HUB 15.8 million tourists in 2017 8 hrs flights 84% of population is between 15 Investor friendly destination 140 airlines and 64 Yrs. 260 destinations to 2/3rd of Quality of life and talent the world retention Dubai Number 1 city for quality International of living across the Middle Airport east and Africa for 5 yrs in 88% of GDP is from a row Ranks #1 in the word Bank’s Financial Corporation logistics performance index Top 10 financial hubs in for MENA region the Bank2017 IFC ranking 4th most visited city in the world

Dubai is a gateway to growth markets with recognized quality of life and ability to retain talent

3 Dubai Health Authority oversees the healthcare sector in the Emirate of Dubai, and the health sector has witnessed significant growth in the past decade

Snapshot of the Key Figures of Dubai’s Healthcare Sector

Regulatory Bodies The number of outpatients, inpatients as well as the number of healthcare facilities and professionals licensed by DHA have seen significant growth in recent years

Outpatients Inpatients OP Volumes (2012-2017, in IP Volumes (2012-2017, in millions) thousands) CAGR 12-17 CAGR 12-17 +6.0% +4.8%

7.3 9. 208 263 8

2012 2017 2012 2017 Number of , per type of setting (2017, in no. of facilities) Private Hospitals Facilities MOHAP Professionals Evolution of the no. of Total number of Total number of licensed Hospitals (2012-2017, licensed facilities by professional by DHA Regulate in no. of facilities) DHA (2014- 2017, in (2014-2017, in thousands) d by thousands) DHCC DHA +10 Hospitals CAGR 14-17 CAGR 14-17 (Private) +3.9% +8.1% 37 27 3. Public 6 6 2.8 1 30.6 38.5 Public 31 21 Private

201 2017 2014 2017 2014 2017 0

4 Health spending in Dubai has risen by 12% p.a. from 2012 to 2017, and there exists opportunities for investment and growth in the health sector

Health spending has risen from AED 9.9 billion in 2012 to 17.5 billion in …and the UAE is one of the top 10 economies 2017, and this is estimated to reach AED 24 billion in 2020, supported by with the most efficient healthcare sector, and health insurance reforms… ranked on top of Middle East countries...

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Aust J expenses) S 17.5 billion Hospitals 47% #1 #2 #7 #8 #10 #11 16.0 billion Clinics 22% Out of 8% Ancillary 2% #12 Pocke Source: Bloomberg Health-Efficiency Index, 2018 12.8 billion13% Pharmacies 9% …however, despite years of positive development, t Outbound there exists potential for growth in the health sector medical tourism 9.9 Insurance & 14% billion 25% 60% Admin & Finance Corporation 52% 6% Healthcare expenditure in Dubai vs. GCC and OECD 22% s Healthcare expenses, by type of care countries (2014, in % of the GDP) (2014, in % of total healthcare 42% 10.0% expenses) 41% Curative care 59% Rehabilitative care 1% 35% 32% Ancillary services 15% 34% Governmen 38% Medical goods 14% 3.6% 3.4% t Preventive care 5% Admin & Finance 6% 2012 201 201 2017 4 6 Dubai GCC OECD

Source: Dubai Health Investment Guide 2018, Health Accounts System of Dubai 2013- 5 2014 Health Investments Strategy is important to Dubai (Health Investment Strategy 2017-20) Projected Capacity Gaps in the Dubai Healthcare Infrastructure Capacity Gap in Other Critical Evolution of Supply-Demand Gap in Inpatient Beds in Dubai, 2020- HealthIncfrastare ructure in Dubai in 2030 2030 In # of beds Suppl Deman Gap: Primary care y d ~1,590 Oversupply Gap: Gap: ~726 OP rooms, by 8,00 ~311 beds 0 : ~654 2030 beds beds 6,00 Long-term care 0 Gap: ~192 beds, by 4,00 2030 0 Rehabilitation 2020 2025 2030 2,00 Gap: ~192 beds, by 2030 0 Specialties with the Largest Inpatient Bed 0 Gaps, 2025-2030 Gap by Specialty in 2030 Gaps, in # of High – Orthopedics Procedural care / Medical beds – Respiratory imaging 225 241 227 medicine • Ultrasound – Pediatric medicine 90 96 89 Gap: ~484 units, by 2030 – Obstetrics – Gastroenterology • Computed tomography Obstetric Orthopedic Pediatric – Psychiatry Gap: ~50 units, by 2030 s s medicin Mediu – & • Mammography e m Cardiothoraci Gap: ~43 units, by 2030 2025 c 203 By 2030, DHA foresees a gap of ~1,590 inpatient beds, mostly– inG enerspecaialtiesl surgerysuch as orthopedics, respiratory medicine, pediatric 0 medicine, cardiology, long term care and obstetrics

6 Note: (*) Ultrasound, X-ray, Computed tomography, Mammography, Magnetic resonance, PET scan, etc.. Source: Dubai Clinical Services Capacity Plan 2018-2030. …leading to investment needs in certain medical specialties in terms of outpatient rooms…

Gap analysis by specialty, in no. of outpatient rooms required (base case, 2018- 2025)

Specialty Gaps (base Specialty Gaps (base case) case) Primary Care 524 696 1,218 Nursing care & 357 463 761 Allied health Orthopaedics and 77 31 75 Rheumatology Trauma and Injury 27 32 44

Respiratory Medicine 10 20 37 1 12 35

Vascular Surgery 4 7 16 Immunology & 11 15 26 Urology 41 27 12 Endocrinology 33 21 13 Renal Medicine 2 3 11 Oncology 8 4 11 Neonatology 3 4 6 Haematology 1 3 7

Gastroenterology 47 35 0 Dentistry 26 19 4

Projections are based on the following assumptions: 1.248 operational days per year 2.8 operational hours per day 3.70% planning occupancy per consultation room 4.Adjustments for National and Non-national utilisation based on current trends 5.Nursing demand has been split between adult and paediatric modes, no supply captured but absorbed by other consultation rooms

Source: Dubai Health Investment Guide 2018, Preliminary results from Dubai Clinical Services Capacity 7 Plan 2018-2030, developed by TAHPI … As well as acute inpatient beds in 2020 and 2025 across certain specialties and services

Gaps by specialty, in no. of additional acute inpatient beds required (base case)

2020 Oversupply Optimum Undersupply coverag (investment Cardio. & needs) General Gyneaec Neuro- Neuro- General Obste- ENT, e Cardiot. medicin Neonologa- Endocrin Pllasogtic Headsurger & neck tolog surger surger trics 10 e y y surgery ology y y y Urology 43 78 y 1 10 10 8

7 Ortho. Gastroen- Renal Onco- Resp. 51 40 35 27 23 16 81 72 & terology Psychiatry logy medicin 10 Rheum. medicine e 16 0 208 9

2025 Oversupply Optimum Undersupply coverag (investment e needs) 167 General Gyneae Neuro- Endocri Neona- Neuro- Plastic ENT, Head 96 10 medicin c surger n tology logy surger 67 77 90 & 43 55 8 e ology y ology y 41 neck 18

6 Renal Genera Cardio. & Gastroen- Obste- Resp. 30 Urolog Psychiatry 33 32 medicin l Onco- Cardiot. terology Ortrtiho.cs & medicin 75 64 y e surger logy Rheum. e 14 13 y surgery 8 5

8 Source: Dubai Health Investment Guide 2018 Health Investments Strategy is important to Dubai (Health Investment Strategy 2017- 20) Priority Investment Areas for Dubai Healthcare Infrastructure Focus of next 2-3 years… Focus for 3-5 years… 1 11 Innovations Preventive Care & in Pharmacy Primary Care beyond- the-pill 2 10 Ambulatory Long-term Care Care 12 and Extended Precision care Medicine 3 9 Urgent and Genetics Care Home-based Clinics care 13 Population 4 8 Health Mental Rehabilitation and Management Health Physical Therapy

14 5 7 Nursing Chronic Diagnostic Health Homes and Disease & Remote Palliative Care Manageme Monitoring nt Tertiary Care 6 for Diabetes, Cardiology and Oncology As part of its Investment Strategy 2017-2020, DHA has started identification of highest priority investment areas to fulfil its objective of promotion and facilitation…

9 Source: DHA Investment Strategy 2017-2020, Advention The Dubai Investment Guide maps the investment journey for different types of facilities / projects for healthcare services

e.g.New facility licensing process map

Source: Dubai Health Investment Guide 2019

10 Key Features of a PPP Model PPP’s are unique in helping create value and transfer of risks to Private Sector

Public Private Participation (PPP) model is a partnership structured between the Public Sector/ Government and the Private Sector to develop infrastructure or provide services to the population based on an agreed allocation of risks and reward to the Private Sector.

The Key Components of a PPP Model are the following – 1. Financing – Identifying and selecting acceptable modes of public and private funding for the project 2. Distribution of risks – assessing and designing a risk distribution model across public and private sector partners 3. Business case – develop a business case that is beneficial and feasible to the public and private sector

11 Source: DHA Investments & PPP’s PPP Models in Healthcare - Examples PPP models have been implemented across developed and developing regions of the world helping drive lower capital costs, more efficiency, improved access and investment in health

Hospitals in Hospital Trusts Hospitals in Spain Canada in UK • Hospital de La Ribera in • 1.1 bn GBP Bart’s Hospitals in New • $ 460 mn Women’s Alzira region for $ 91 Health Trust NHS Zealand College Hospital – mn. Payment through hospital and 430mn GBP Design, Build, Finance capitation fees and Maintain (DBFM) Bristol Trust NHS • $ 215 mn Burwood Hospital in Christchurch with 230 beds Hospitals in Turkey

• Eur 360 mn 1,000 bed Bumrungrad Hospitals in Intl. Hospital hospital in Elaziğ. 26 Australia PPP’s planned • $365 mn Royal Women’s Hospital in Victoria, Australia Hospitals in Canada • $ 352 mn Joseph Brant Hospital with 172 beds. Design, Imaging Tele- in Build and Finance Diagnostics in Kenya (DBF) Brazil • GE partnership with • $ 40 mn project in the Kenya to deliver State of Bahia to set up teleradiology to 46 mn and operate 45 new people across 98 equipment across 12 hospitals hospitals 12 Source: DHA Investments & PPP’s PPP Law and Guidelines in Dubai Dubai has a PPP Law and PPP Guidelines developed by the Dept. of Finance (DoF) to support investments in healthcare, transport and other infrastructure projects for the Emirate

Dubai PPP Law and Guidelines DHA is very focused on implementing models that are suited and tailored to Dubai’s needs and that are within the framework of the PPP Law no 22 of 2015. PPP Guidelines issued by DoF governs different models of PPP’s for both greenfield and brownfield facilities and we are reviewing and proposing different types of models that are suited to different projects provided these allow for risk sharing and risk transfer to the private sector

Focus of PPP Law and Guidelines in Dubai– 1. Description of the different types of PPP’s allowed and level of investment 2. Evaluation and approval of PPP’s 3. The process for development and approval of a PPP project 4. Payment Mechanisms and Risk Allocation and transfer

13 DHA is implementing a PPP Project for Cardiology CoE The Cardiology CoE is the first healthcare PPP project to be implemented in the Emirate of Dubai and aims to bring world-class cardiology services in partnership with private sector

Highlights of CCoE and PPP Model Objectives of the Cardiology CoE*

• The Cardiology CoE is expected to be a 100-120 bed One –stop- dedicated cardiology hospital focusing on cardiac ER, OP Evidence based and IP services; shop approach international best with integrated • DHA aims to implement a DBFM PPP Model with the below practice with focus on stated sharing of responsibilities between the Public & Pvt. care continuum screening and early Sectors with the term of the PPP agreement of 25 years detection • The CoE will be co-locatedSelected within PPP Model the Rashid - DBFM Hospital ResponsibilityComplex (Design-Build-Finance-and Maintain, “DBFM”) with clinical affiliation Physician access to clinical affiliation, Revenues DHA Sustainable research & and predictable technology Capex Private Sector costs with innovation access to Opex Private Sector (excl. Clinical Salaries paid by DHA) financially vulnerable Selected medical and nursing positions by DHA segments Clinical Staff (40-50% of clinical staff), Clinical Affiliation partner Focus on physician to support recruitment & development It will be flexible and training, development adaptable to support Non-Clinical Private Sector is free to recruit and deploy staff for and education in Dubai Staff the suited positions remote patient monitoring DHA  PPP Co Availability Reflects capex and opex incurred by PPP Co, along Payment with cost of funding (debt & equity)

14 DHA is also evaluating opportunities for PPP in 2020-24 Other PPP projects range from developing new infrastructure to enhancing existing DHA services and improving access to care for the patient popuOvervilateiwonof other proposed PPP projects in service enhancement and improvement Imaging Diagnostics . DHA is keen to improve utilization of equipment, quality and efficiency of services and training of staff . Possibility of a risk – share partnership to manage radiology services of 3 hospitals (retaining DHA staff) to reduce waiting times and increase revenues Improved . Training and upskilling DHA staff will be a key component  Efficiencies

Sustainability of Dialysis . Operating Agreement for managed services model to manage dialysis services for patients in Dubai  Services . To focus on efficiency, patient convenience and quality of outcomes (incl. access to care) Better Quality . Needs to interface with primary care  Outcomes Spine . Operating Agreement for managed services model to manage spine services in for patients in Dubai Improved Access . To focus on cost of care, patient trust and quality of outcomes (incl. access to care)  to Specialized Care . Objective is to bring best in class, highly qualified and experienced surgeons to Dubai through this Cost  Reduction and Diabetes . Service enhancement and clinical affiliation for Dubai patients in diabetes care Control . To focus on cost of care, efficiency and quality of outcomes (incl. access to care) Increase . In future it could include take over and turnaround of an existing center focused on UAE  in National Revenue patients Grow Patient Long Term . Concession Model or Operator Agreement for managed services model to manage LTC  services for Volumes Care patients in Dubai . To focus on efficiency, patient experience and quality of outcomes (incl. access to care) . Expected to free up beds and critical care units in Rashid and Dubai Hospitals 15 Thank You