Over the past couple of decades a key theme for South African investors has been to see their blue-chip companies seek expansion opportunities outside the country to deal with the discount associated with political risk at home.
Hospital groups have not been immune to these pressures, but about 12 years after venturing into the UK, Netcare's scorecard doesn't make for good reading.
The question is just where the growth is, as the most recent results from Netcare, Mediclinic and Life Healthcare reflect the challenges they face outside SA, while battling a domestic market that is seemingly mature.
After a period of high-volume growth from 2008 until 2015, the past three years had been difficult for hospital groups, said Samantha Hartard, a portfolio manager at Investec.
In 2014, SA's population of insured lives was 8.8-million. Four years later, the figure is unchanged.
Hartard said the stagnant growth in insured lives was exacerbated by the pressure on hospitals from medical aids trying to curb admissions.
"You had volume growth come down for those two reasons - no increase in privately insured lives and the funders [medical aid schemes] coming through and clamping down on the volumes of admission.
"So suddenly you had an environment back in 2012, where volume growth was at about 6%, to it turning down to negative territory in 2017 and 0% growth in the second half of this year," she said.
Hartard said tariffs contributed to the pain the hospital groups were feeling because people who are insured are downgrading their medical aid cover to cheaper options.
Hartard described the three hospital groups as having "wonderful" South African businesses diluted by overseas ventures.
"I think they've really struggled in these developed markets and I think it is taken positively by the market that Netcare has left the UK because it was a capital drain. So them coming back and focusing on SA certainly makes Netcare a higher-quality business going forward," she said.
Netcare disposed of its controlling stake in BMI Healthcare in the UK in March, leaving it with its operations in SA.
Ambitions in the developed climes haven't been realised, but there seemingly isn't much opportunity to expand to SA's neighbours either as private medical insurance has not taken off in the rest of Africa.
Reuben Beelders, portfolio manager at Gryphon, said infrastructure constraints would make it difficult for hospital groups to move into the rest of Africa for growth opportunities.
"I believe that hospital groups will have every opportunity to grow volumes. However, technology will, as it has in all professions, result in pressure on margins.
"Hospital groups who are able to adapt to this new environment while maintaining quality care and engagement with their clients will thrive," he said.
Speaking after his results presentation last month, Netcare group CEO Richard Friedland said the group would focus on a digital strategy rather than bricks-and-mortar hospitals, which would give patients access to personalised technology and information on their care.
"Our focus is entirely on SA and we want to lead in positive changes to health and care. Our biggest strategy at the moment is around digitising our entire network," he said.
Mediclinic has not had an easy year, with its Hirslanden operations in Switzerland dragging down its performance and leading to an operating loss. At the heart of its woes were regulatory changes in one of the world's richest countries.
"I'm acutely aware of our shareholders and how much they have suffered through this period of regulatory change," said the company's recently appointed CEO, Ronnie van der Merwe.
Van der Merwe said Mediclinic's focus would be on cost-cutting and saving measures at its Swiss operations.
In the two years since it re-listed on the JSE and merged with Abu Dhabi-based Al Noor Hospitals Group, Mediclinic's share price has dropped about 70%.
Life Healthcare has also struggled, with its share price tumbling almost 21% in the same period while Netcare's fell by more than 24%.
Due to their challenges, Hartard said, hospital groups had to look beyond acute health care for growth.
Earlier this year Netcare acquired mental health-care group Akeso Clinics for R1.3bn after a surge in demand for mental health-care services. Life Healthcare is continuing to grow its mental health-care facilities and is set to open a new 80-bed facility on the East Rand, in Gauteng, in the second quarter of 2019.
Shrey Viranna, who was appointed Life Healthcare CEO earlier this year, said 35% of its income now comes from outside its acute hospital business. He said the group was moving towards being a health-care provider as its core business, rather than an acute-care-focused hospital group.
Viranna said Life Healthcare's international operations had all had regulatory, legislative, competitor, customer and operational changes that had had an impact on contract negotiations, tariffs, investment decisions and business growth...