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European Hospitals Turn To Sustainability-Linked Financing To Advance Their ESG Goals

During the pandemic, hospitals and other health care facilities came under unprecedented pressure to not only handle the surge of COVID-19 patients, but also to protect their staff from the virus, prevent employee burnout, and deal with an increased amount of hazardous waste and the proliferation of more frequent cyberattacks.

The sector has always dealt with shortages of qualified medical staff, but the pandemic only accentuated the situation, increasing the mental and physical strain on employees, with potential long-term implications for their health and safety. During the pandemic, the sector used more disposable medical products and generated more infectious waste. In addition, since the start of the outbreak, the number and intensity of cyberattacks on hospitals and other health care facilities rose dramatically, largely because these sectors hold troves of personal health data.

After the initial shock passed, some hospital operators took the opportunity to review their polices and protocols, adopt new technologies to improve operational efficiencies and patient and staff care, and define their overall sustainability strategies.

Sustainability-linked financial instruments are one way these companies can raise funds while highlighting their green or social commitments and reinforcing their sustainability strategy to investors, lenders, and the public. Since the beginning of 2021, we have seen a steep rise in sustainability-linked loans (SLLs) issued by the European health care sector, reaching €6.3 billion as of May 2021, with health care services companies being the most active. France-based hospital operators Elsan SAS, Ramsay Générale De Santé (RGDS), and Finland-based provider of private health care and social services Mehilainen refinanced their existing loans with new sustainability-linked loans totaling €4.3 billion.

Chart 1


Sustainability-linked instruments could be one way that health care companies answer calls to pay greater attention to social factors while protecting their bottom line and their credit quality.

Social factors are part of our credit analysis on health care services companies because they provide an essential service to the communities where they operate. While many of these services benefit society, they can also be costly to the payers—the government, private sector, or consumers—although the consumer is always footing the bill in the end because the cost is socialized through insurance premiums or government taxes.

Aging populations are increasing costs for health care systems. This also contributes to reimbursement risk, which is already constraining the ratings on providers, particularly hospitals, which deliver the most expensive of health care services. Reimbursement cuts, lower rate increases, and efforts to move more volume to the lowest-cost sites of care can diminish the financial profile of these companies. We view companies that are readily able to address and adapt to these social risks more favorably from a long-term sustainability and overall credit quality perspective.

Bettering health outcomes while improving the cost effectiveness of therapies are increasingly becoming twin goals for health care companies. Public debate focuses on the accessibility and the affordability of medicines and quality care—including price transparency. Increasingly, payers are advocating that health care providers be compensated for the overall value they bring to the society, to better align incentives. Data protection has also become a notable social risk considering emerging data privacy and protection laws.

Issuance Of Sustainability-Linked Instruments In The Health Care Sector Is On The Rise Globally

Given their innovative features and characteristics, which include a high degree of flexibility regarding use of proceeds, sustainability linked instruments have broadened the universe of issuers who can obtain sustainable financing. This has particularly been the case for companies in the health care sector, which often don't have sufficient capital expenditures connected to sustainability projects to issue a use of proceeds instrument such as a green, social, or sustainability bond. As a result, we have seen a rapid increase in the use of sustainability-linked instruments across the sector, linked to a variety of environmental and social performance indicators.

Through the issuance of sustainability-linked instruments, we believe that health care service companies can be influential in the social and environmental arena by focusing on and aligning their strategies with the following UN Sustainable Development Goals (SDGs):

  • Goal 3: Good health and well-being: Ensure healthy lives and promote well-being for all at all ages. Achieve universal health coverage, including financial risk protection, access to quality essential health care services, including increased access to physicians and access to safe, effective, quality, and affordable essential medicines and vaccines for all.
  • Goal 5: Gender equality: Achieve gender equality and empower all women and girls. Women play a disproportionate role in responding to the virus, including as frontline health care workers and careers at home. Women's unpaid care work has increased significantly as a result of school closures and the increased needs of older people. Women are also harder hit by the economic impacts of COVID-19, as they disproportionately work in insecure labor markets.
  • Goal 8: Decent work and economic growth: Promote inclusive and sustainable economic growth, employment, and decent work for all. Protect labor rights and promote safe and secure working environments for all workers. Promote development-oriented policies that support productive activities, decent job creation.
  • Goal 12: Responsible consumption and production: Ensure sustainable consumption and production. By 2020, achieve the environmentally sound management of chemicals and all wastes throughout their life cycle. By 2030, substantially reduce waste generation through prevention, reduction, recycling, and reuse. Encourage companies, especially large and transnational companies, to adopt sustainable practices and to integrate sustainability information into their reporting cycle
  • Goal 13: Climate Action: Take urgent action to combat climate change and its impacts. Although greenhouse gas emissions (GHG) are projected to drop about 6% in 2020 due to travel bans and economic slowdowns resulting from the COVID-19 pandemic, this improvement is only temporary. Climate change is not on pause. Once the global economy begins to recover from the pandemic, emissions are expected to return to higher levels.

However, as the sustainability-linked instrument market is relatively new, key challenges to the market still exist (see "How Sustainability-Linked Debt Has Become A New Asset Class," April 28, 2021). In our view, the main risk for sustainability-linked instruments in the health care sector is that KPIs and SPTs are too specific to the individual company, which limits comparability of one set of SPTs or KPIs to another across individual entities. This is especially true for instruments linked to social targets since social KPIs are much harder to define and quantify than environmental ones.

Among the social SPTs set to date, the most prevalent are patient satisfaction and access to care. Regarding patient satisfaction, comparability among French hospitals and medical clinics should be easier as these are collected and calculated via online poll e-Satis and managed by an external evaluation agency, where patients who spent more than 48 hours in a hospital assess the care received. Patient satisfaction is increasingly important as French public authorities are providing incentives based on quality care through the government's IFAQ (Incitation Financière à la Qualité) scheme. Both Elsan and RGDS have a KPI of improving patient satisfaction by 0.3%-0.4% and 0.5% each year, respectively. Mehilainen bases its patient satisfaction score on an internally developed quality index, with a SPT of 2% improvement each year.

We believe that social targets related to access to care will likely be the most diversely defined and therefore their SPTs and KPIs will have low comparability. For example, in France, RGDS defines its access to care KPI as the number of consultations benefitting from proximity care services and in Sweden, access to care is measured by the number of teleconsultations benefitting from Telemedicine. On the other hand, Mehilainen defines its access to care KPI as patients being able to book an appointment for non-urgent care within seven working days.

Although supporting a long-lasting and productive workforce is a key social risk factor in the health care sector, currently only RDGS has a KPI linked to health benefits for employees, defined as the percentage of beneficiaries having access to Ramsay Santé's new health plan. Furthermore, we have not observed any KPIs linked to gender diversity and support for working women, which is concerning, especially since most health care workers are female. Yet, women hold only a small proportion of higher management positions.

On the environmental front, the SPTs set by European hospitals and health care providers are more clearly defined and measurable, including those tied to reductions in GHG emissions and regulated infectious medical waste generation.

Examples of SPTs used in recent transactions in European health care facilities

Table 1

How Ramsay Generale de Sante Used SPTs In Recent Transactions
Sustainability target
KPI SPT Type Sustainability goals Definition of KPI Base line 2021 2022 2023 2024 2025 2026 2027
KPI1 Patient satisfaction Provision of high-quality patient care, excellence of standards, safet,y and accreditations The average of the annual inpatient E-satis survey (>48h) of Ramsay Santé France, the annual outpatient E-Satis survey, the SSR (Rehab) E-Satis survey, and the annual net promoter score of Capio in Sweden. 73.82 Increase at least by 0.5 the average score per calendar year compared to previous calendar year.
KPI2 Access to care Medical care for underserved population and preventive health care Number of consultations benefiting from proximity care services in France and number of teleconsultations benefitting from Telemedicine in Sweden. 112,500 At least 176,960 consultations At least 299,584 consultations At least 535,528 consultations At least 880,265 consultations At least 1,274,456 consultations At least 1,595,900 consultations At least 1,768,031 consultations
KPI3 Health and safety Improving quality of work life; Preventive health program for employees Percentage of beneficiaries having access to Ramsay Santé new health plan, currently deployed and aiming to increase access to preventive health care services. N.A. No annual target At least 50% of direct employees and their families At least 100% of direct employees and their families At least 50% of medical practitioners No annual target At least 100% of medical practitioners At least 100% of retired staff
KPI4 GHG emissions reduction Reduction of the environmental impact (reduction of S1 and S2 MtCO2e) Percentage of reduction of absolute Scope 1 (direct emissions from own activities) and the absolute Scope 2 (indirect emissions from energy, steam, and heating/cooling purchased from third parties) of all the facilities of Ramsay Santé located in France, in KtCO2e. 64.6KtCO2e Annual emissions reduction target of at least 2% per calendar year compared to previous calendar year, except for 2021, where the comparison will be made by reference to calendar year 2019.
GHG--Greenhouse gas emissions. KPI--Key performance indicator. SPT--Sustainability performance target. N.A.--Not available. Source: Company reports.

Table 2

How Elsan Used SPTs In Recent Transactions
Sustainability targets
KPI SPT Type Sustainability goals Definition of KPI Base line 2021 2022 2023 2024 2025 2026 2027
KPI1 Patient satisfaction Improving patient experience Patient satisfaction percentage based on a weighted average of the inpatients and outpatients’ satisfaction on the basis of the number of patients treated as calculated and published by the E-Satis Survey. 75.60% 76.70% 77% 77.40% 77.70% 78.10% 78.40% 78.80%
KPI2 Waste management Reducing environmental footprint (reduction of volumes of regulated infectious medical waste) Volume of regulated infectious medical waste per medical stay 2.75 kg/stay 2.64 2.56 2.48 2.48 2.48 2.48 2.48
KPI3 Health and safety Offering a high-quality work environment Percentage of service units enrolled in the ProximElsan Program or any other similar dedicated quality of work life program 0% 16% 28% 40% 53% 68% 83% 100%
GHG--Greenhouse gas emissions. KPI--Key performance indicator. SPT--Sustainability performance target. The ProximElsan Program refers to the program implemented by the Sustainability Group with a view to enhancing the quality of work life by achieving three objectives: the enhancement of employees’ health and the reduction of accidents; the improvement of services provided to the patient through an enhanced communication of needs; and the reduction of employees’ everyday irritants. Source: Company reports.

Table 3

How Mehilainen Used SPTs In Recent Transactions
Sustainability targets
KPI SPT Type Sustainability goals Definition of KPI Base line 2021 2022 2023 2024
KPI1 Access to care Access to non-urgent care at Mehilainen’s public health centers The third available appointment (T3) within seven working days. 5.6 days 7
KPI2 Patient satisfaction Continuously improve the quality of care services for the elderly Quality Index, developed by Mehilainen, which consists of five areas: individual care and support, safety, own cosy home, sense of community and participation, as well as tasty and healthy food. Index survey is made in the units and the data consists of residents’, employees’ and relatives’ feedback and experience. The index score is calculated using feedback from residents, their relatives and employees. 76.8 points 78 80 82 83
KPI3 GHG emissions reduction Reduction of carbon dioxide emissions in relation to revenue The ratio of the emissions (total carbon dioxide) for that financial year to the total revenue of the group 97% Improving by 3% each year
GHG--Greenhouse gas emissions. KPI--Key performance indicator. SPT--Sustainability performance target. Source: Company reports.

Another weakness of the sustainability-linked instrument market is that, in some cases, the financial penalty for failing to meet the predetermined targets may not be material enough to encourage the company to deliver on its goals or track them frequently or reliably enough to ensure it is demonstrating significant sustainability performance improvements over the life of the instrument. Of recently issued instruments, missing all KPIs would add €1 million to the cost of funding for Mehilainen (€38 million in interest expenses paid versus €37 million), €2.6 million for Elsan (€65 million in interest expenses paid versus €62.3 million) and about €1.45 million for RGDS (€37.7 million interest expenses paid versus €39.1 million). We will be closely watching whether these adjustments provide a sufficient financial incentive for the companies to meet their goals in the specified time frame.

Table 4

Sustainability Linked Loans Issued By European Health Care Services Providers: Key Terms
Issuer Rating Facility Yield Margin adjustment KPI - Social KPI - Environmental

Mehilainen Oy

B/Stable €1.06 bil. term loan B 3.67% '+/- 0.10% if no or all targets mets, -0.05% if 3 or 2 targets met Access to care; patient satisfaction Reduction of CO2 emissions

Ramsay Generale de Sante

BB-/Stable €1.45 bil. term loan B split into two tranches 2.36%, 2.82% '+/- 0.10% if no or all targets mets, -0.05% if 3 targets met, 0% if 2 targets met, +0.05% if 1 target met Access to care; patient satisfaction; quality of worklife Reduction of CO2 emissions

Elsan SAS

B+/Stable €1.755 bil. term loan B 3.55% +/- 0.15% if no or all targets mets, -0.1% if 2 or less targets met; +0.1% if 1 target is met Patient satisfaction; quality of worklife Medical waste reduction
GHG--Greenhouse gas emissions. KPI--Key performance indicator. SPT--Sustainability performance target. Sources: Company reports.

Aside from being a funding instrument, health care issuers see sustainability-linked instruments as a tool for supporting communication about sustainability to stakeholders. Despite soaring sustainability-linked issuance, demand continues to outstrip supply and investors seem to be willing to forego some yield to support companies' sustainability objectives.

Key Sustainability Themes For Health Care Facilities Operators

Social themes

Putting patients at the center, with a focus on quality and access to care.   Health care facilities play an important role in easing the patient pathway and promoting preventive care. Providers are making efforts to improve patient satisfaction, not just for the care received but for the overall patient experience. Engaging third parties to conduct regular surveys with clearly established plans of action to drive improvements should be beneficial not just for patients, but also for the reputation of the provider. Strong reputation and high standing in quality care rankings will become increasingly important because national health authorities in many countries are linking parts of reimbursements to quality of care in so called pay-for-performance schemes.

COVID-19 further highlighted the importance of robust quality assurance and risk management strategies that hospitals put in place. These include clearly defined and continuously monitored and updated best practices and protocols implemented across the whole organization. A special focus should be placed on reporting procedures for adverse incidents, with clearly defined preventive and corrective measures. Adoption of digital technology can enhance day to-day improvements, enabling companies to streamline and better oversee processes, save time, and reduce errors.

Implementation and use of innovative technology is also a way to increase quality and efficiency of care provided. Contributing to patient satisfaction will be investments to technology and equipment that improve procedural efficiency, connectivity, personalization of patient care, as well as patient wellbeing by making treatments less stressful.

Preventing occupational health and safety issues while investing in talent attraction and development.  The COVID-19 pandemic has stressed the capacity of hospital and other health care facility workers to cope both with physical and mental exhaustion caused by a multitude of factors including: working long shifts while wearing uncomfortable personal protective equipment, handling difficult ethical discissions, caring for critically ill or dying patients, carrying the fear of transmitting infection to family members, and learning new protocols while supporting trainees and volunteers. COVID aside, under normal circumstances burnout syndrome, anxiety, depression, and other forms of stress affect medical staff--especially those carrying for critically ill patients. As such, it is vital that health care companies have programs in place that monitor and improve safety and wellbeing of employees focusing on reduction of absenteeism due to workplace accidents and occupational hazards and ensuring the quality of work-life balance, especially given the large the proportion of female employees in nursing and other health care service roles.

Women represent close to 70% of the health care workforce globally and account for most nurses and midwives. In EU health care overall, the percentage of employees who are women stands at 75.7%. While women occupy a large share of entry-level line roles, that declines rapidly at more senior levels due to advancement opportunities. Women, and especially women of color, are more likely to be in caregiving roles than diagnosing roles. There is a 28% gender wage gap in health care around the globe. A worldwide shortage of about 18 million health care workers is projected by 2030. The World Health Organization suggests that this shortage, a consequence of anticipated demographic changes and economic growth, could be mitigated by gender equality initiatives.

Attraction of a highly qualified, motivated, and diverse workforce is key for sustainable growth. Strong brand equity can be supported by providing opportunities for training and talent development (for example, supporting research projects carried out by doctors and investing into innovative medical equipment, which attracts high-skilled labor). In addition, regularly carried out employee engagement surveys, with clearly defined improvement targets and solutions, implemented consistently across the organization (albeit reflecting regional differences) are vital to strengthening companies' employee engagement, brand, and reputation, provided these efforts lead to substantive and enduring workforce improvements. Active engagement with employee representative organizations is also key to promoting a healthy social dialogue and improving the satisfaction and motivation of the workforce.

As facilities increase their use of and reliance on data, more stringent cybersecurity measures become critical.   During the pandemic, a variety of cyber-attacks targeted health care providers, some of which locked up systems and disrupted operations. Using ransomware attacks, criminals tried to obtain sensitive data such as patient records, including personal and medical research data. Some recent attacks resulted in diagnostic delays where patient care suffered (for example, attacks on hospitals in Brno in the Czech Republic as well as Oloron-Sainte-Marie, Dax, and Villefranche-sur-Saône in France). As medical device and health care services systems are becoming increasingly connected, the exposure to attacks has been elevated. It is therefore imperative that providers invest in modern IT infrastructure with patch management and malware protection, alongside staff training.

Taking a more proactive role in shaping both the national and regional health care systems.  We believe the main social role of health care facilities is to provide access to affordable and high-quality care. As health care in Europe is predominantly funded from public resources (state budgets), health care companies must be proactive in communication with the payers, including regional governments regarding the organization and funding of the health care system. This should allow for greater visibility into long-term investment programs, which providers can use in their budgeting strategies.

Most countries suffer from a shortage of local health care providers offering specialized care, disadvantaging those less mobile like the elderly or disabled. As a part of the solution, providers are increasingly adopting alternative methods of connecting with patients using telemedicine solutions to help patients through administrative and medical procedures. Health care pathways are complex, including anything from diagnosis to consultation, treatment, and rehabilitation, requiring the collaboration of numerous departments, tools, and systems. As a result, data collection and automation can help to overcome the shortage of specialist care, especially in more remote areas. One positive outcome of the pandemic is the adoption of digital technology by the segments of population that were previously hesitant to use it. As these tools become more widely adopted, adequate reimbursement should follow, in-line with the shift toward outpatient services encouraged by public health policies.

Working with communities to better reflect needs of the local environment.   Hospitals and other health care services facilities provide essential services and are an integral part of local communities. Large hospitals and other health care facilities tend to be large local employers and as such, key contributors to the local economy through jobs and public health campaigns, for instance. To help shape the local environment, companies can work with local suppliers and providers of services to support youth employment and training through apprenticeship schemes. In addition, they can help local organizations and public authorities by promoting health and prevention through vaccinations, and public health awareness and screening campaigns.

Environmental themes

GHG emissions reduction is a key sustainability objective for many health care service providers, even though the industry is not among the major emitters.  The health care industry itself is responsible for about 5% of global annual CO2 emissions. About 60% of total emissions are indirect, related to procurement. Other sources of GHG emissions include building energy consumption, use of nitrous oxide in medical procedures, and employee, patient, and visitor travel. Health care companies can reduce their GHG emissions footprint directly by improving insulation and by implementing building control and monitoring systems (such as by installing LED lighting and motion detectors and regulating heating and ventilation in dormant facilities). As health care operators tend to lease their facilities, close cooperation and planning with landlords is important in achieving meaningful GHG reductions.

Chart 2


A specific issue to hospitals is use of nitrous oxide (N2O/laughing gas) during surgical procedures for anesthesia. Globally, anesthetic gases are estimated to contribute to 0.6% of health care's total climate change impact. Although the effect on the atmosphere compared to other sources of ozone-depleting chemicals and greenhouse gases is small, it is not negligible. However, as the trend in surgery continues to move toward shorter hospital stays and more ambulatory cases, anesthetics that facilitate a rapid recovery such as intravenous agents have gained greater preference, reducing the use of N2O.

Transportation, including staff and patient travel, is another contributor to the carbon footprint. Health care companies can reduce emissions produced from transportation, for example, by using a fleet that runs on alternative fuels or electricity, offering incentives for staff and patients to use public transport, cycle, or walk to the health care facility, moving delivery of care closer to home, and using digital technology to connect with patients to reduce the need for patient to travel.

Finally, GHG emissions are generated in the upstream supply chain. To lessen these emissions, companies can work with suppliers that adhere to environmental values and source environmentally responsible and local products.

Waste reduction and recycling are at the forefront of environmental policies, specifically as volumes of infectious waste and single-use products grow.   During the pandemic, demand for PPE rose to unprecedented levels and more waste than ever before was produced in health care facilities. This included infectious medical waste associated with patients suspected or confirmed with a COVID-19 infection. Such waste, which includes not only PPE like surgical gloves, masks, and surgical gowns but also other waste such as disposable bedsheets, food and dining boxes, or infusion bottles and bags, requires high-energy disposal processes, including incineration in some cases.

COVID-19 aside, the proliferation of single-use products to limit cross-contamination and decrease hospital-acquired infection rates will not make it easy for health care facilities to reduce volumes. However, as about 85% of waste generated by health care facilities is non-hazardous, providers can develop strategies and systems to improve waste segregation to improve waste management and recycling outcomes (for example, by segregating electronic equipment, paper, plastic, metal, and glass). This can also target a reduction in food waste and responsible purchasing. Where possible, companies may adopt more environmentally friendly ways to treat hazardous waste (for example, autoclaving or microwaving).

Table 5

Types Of Waste In The Health Care Sector
Type Examples
Infectious waste Waste contaminated with blood and other bodily fluids (for example, from discarded diagnostic samples), cultures and stocks of infectious agents from laboratory work (like waste from autopsies and infected animals from laboratories), or waste from patients with infections (swabs, bandages, and disposable medical devices)
Pathological waste Human tissues, organs, fluids, and body parts and contaminated animal carcasses
Sharp waste Syringes, needles, disposable scalpels, and blades
Chemical waste Solvents and reagents used for laboratory preparations, disinfectants, sterilant and heavy metals contained in medical devices (like mercury in broken thermometers) and batteries
Pharmaceutical waste Expired, unused, and contaminated drugs and vaccines
Cytotoxic waste Waste containing substances with genotoxic properties (for example, highly hazardous substances that are mutagenic, teratogenic, or carcinogenic), such as cytotoxic drugs used in cancer treatment and their metabolites
Radioactive waste Products contaminated by radionuclides including radioactive diagnostic material or radiotherapeutic materials
Nonhazardous or general waste Waste that does not pose any particular biological, chemical, radioactive, or physical hazard
Source: WHO.

Water conservation and protection can save costs and benefit the environment.  The largest sources of demand for water in hospitals is by staff and patients for hygiene purposes, followed by cooling equipment and medical process rinses. Providers can implement small behavioral adjustments and operations and maintenance fixes that can result in initial savings (economy-flush toilets, tap flow regulators, and staff awareness actions). They can also adopt solutions to help protect water quality, including body fluid filtration systems in operating theatres, dilution control units for cleaning products, use of eco-certified products rather than biocides, along with steam disinfection systems, grease traps in kitchens, and fuel/oil separators in car parks.

Chart 3


Governance themes

Strong board effectiveness and oversight are key to maintaining sustainable operations.  It starts with the board and its ability to formulate a strategy which supports the long-term vision and objectives of the company and shapes a patient-focused culture. Health care is a highly regulated industry, and as such strong governance plays a significant role in maintaining sustainable operations. Health care facilities should be held accountable for ensuring the continuous improvement of service quality and safety. Principles and policies should be clearly formulated and set out in formal documents, including antibribery and whistleblowing. Transparency and disclosure around incentive structures and financing polices should be clearly articulated and made publicly available.

Related Research

This report does not constitute a rating action.

Primary Credit Analysts:Marketa Horkova, London + 44 20 7176 3743;
Lori Shapiro, CFA, New York + 1 (212) 438 0424;
Thomas Englerth, New York + 1 (212) 438 0341;
Secondary Contacts:Solene Letullier, Paris + 33 1 40 75 25 54;
Nikolay Popov, Dublin + 353 (0)1 568 0607;

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