CUF SGPS SA

Rating Action and Rationale

• EthiFinance Ratings affirms CUF SGPS S.A’s long-term rating at BBB-, maintaining its Stable outlook.
• CUF, founded in 1945, is one of the most experienced players in providing private health care in Portugal, whether in person through its national network of hospitals and clinics, at patients’ own homes or virtually.
• Although CUF SGPS S.A.’s standalone rating is higher, its final rating is capped by the credit rating of CUF SA, internally assessed but not publicly disclosed. This is primarily due to the fact that the debt is not entirely located at the subsidiary level, despite the subsidiary representing 97% of total sales. At the consolidated level of CUF S.A, we highlight the following:  
  • The rating is supported by the group’s strong business profile based on its leading competitive positioning in Portugal and robust governance within a sector that presents favourable fundamentals (high barriers to entry, low volatility of profitability and stable growth prospects).
  • On the other hand, the rating is constrained by the group’s still relatively high leverage (adjusted NFD/EBITDA of 4.0x and FFO/NFD below 20% on average) and low financial autonomy (equity/TFD of 40% on average), which weaken the overall financial profile.
  • It is worth highlighting that the low volatility table has been applied to the calculation of credit metrics, based on an industry which shows a proven track record of stability over long-term economic cycles.
• In line with our methodology, the healthcare equipment and services sectors have medium to low ESG risks (sector heatmap score between 2 and 3). This results in a sector assessment which is not impacted by industry-related considerations. On the other hand, the group’s ESG policy is considered to be good (ESG score between 1.0 and 1.5), resulting in a positive impact on the financial profile (+half a notch).
• The rating assessment incorporates financial projections for the 2026–2028 period, which are not disclosed in this report due to their confidential nature.

Company Description

CUF, founded in 1945, is one of the most experienced players in providing private health care in Portugal, whether in person through its national network of hospitals and clinics, in patients’ homes or virtually. The group offers a wide range of services (consultations, exams, hospitalization, maternity care, intensive care, palliative care, surgeries, etc.). It also has other secondary activities, in the infrastructure sector, and in training and research.

In 2025, the CUF network consisted of 44 units (hospitals, clinics and health centers) with presence in Lisbon, Setúbal, Santarém, Leiria, Coimbra, Aveiro, Viseu, Porto and Açores. The centers of the group can be classified under the following categories:

• Large hospitals: includes its 3 biggest units: CUF Tejo, CUF Descobertas and CUF Porto.
• Medium‐sized hospitals: the group manages 9 medium‐sized hospitals. These hospitals are designed to cover second-tier towns in terms of population.
• Proximity clinics: these are designed to increase proximity to its clients throughout the country. The group manages 19 proximity clinics.
• Health centers: offer personalized monitoring to prevent, diagnose and treat diseases. The group has 13 health centers.

At end-2025, the group reported a total of 78 operating theatres, 976 consulting rooms, 807 beds and 17,055 employees. The main metrics were as follows:

At CUF SGPS level, turnover amounted to €936.4m in 2025 (+8.9% YoY), with EBITDA of €170.4m and an EBITDA margin of 18.2%. Adjusted NFD/EBITDA stood at 2.3x. At CUF S.A. level, turnover amounted to €962.2m in 2025 (+8.8% YoY), with EBITDA of €162.4m and an EBITDA margin of 16.9%. Adjusted NFD/EBITDA stood at 3.6x.

During 2025, CUF reached an agreement with the shareholders of Grupo HPA Saúde to acquire 75% of the group. Grupo HPA Saúde strengthens CUF's national network, adding 22 healthcare units, comprising 5 hospitals and 17 clinics. The group has 30 years of operating history and a presence in the Alentejo and Algarve regions, as well as in the Autonomous Region of Madeira. Completion of the transaction was subject to the conditions set out in the agreement, including approval from the Competition Authority, and was finalized at the end of January 2026, with the integration of these units taking place throughout 2026.

In 1H2026, following the inclusion of Grupo HPA Saúde in the consolidation perimeter, CUF SGPS reported turnover of €584.7m (+24.8% vs. 1H2025), EBITDA of €110.5m and an EBITDA margin of 18.9%. Adjusted NFD/EBITDA stood at 2.6x. At CUF S.A. level, consolidated turnover amounted to €598.3m (+24.3% YoY), with EBITDA of €106.3m and an EBITDA margin of 17.8%. Adjusted NFD/EBITDA stood at 4.0x.

Corporate Structure

CUF SGPS operates the private healthcare business within CUF corporate structure, among other services through 26 subsidiaries. 

CUF Corporate structure

Source: Financial accounts FY2025.

Fundamentals

Business Risk Profile

Industry Risk Assessment

• Sector characterized by medium profitability margins (at the EBIT level), high barriers to entry, low correlation to macroeconomic trends and positive long-term prospects.

Healthcare is a fundamental right in Portugal’s social security system, making the State the main operator in the market. The private healthcare sector in Portugal is fragmented given the large number of private hospitals (more than 100) and a significant number of private consultations owned by independent doctors, although dominated by a few, well‐known companies with large geographic footprints, such as CUF. Insurance companies are the most relevant clients for the private healthcare providers in Portugal, such as Médis, Multicare, Advance Care, Victoria or Allianz. There is an intensive price war between private insurances which reduces the bargaining power of health providers. That, coupled with the presence of the government and the still low concentration of the market, intensifies the levels of competition and results in medium profitability margins although with a very low level of volatility given its essential characteristic. This situation has led large healthcare companies to implement different strategies focused on offering higher value-added services and to accelerate M&A activities. 

The barriers to entry are considered high given the relevant capital and R&D investments required (facilities, highly innovative equipment, qualified staff, regulation, etc.), significant know-how, expertise and brand recognition that are necessary to be competitive and to stand out within the industry. In the case of large private hospital groups, the presence of economies of scale through suppliers (equipment, materials, etc.) and a strong brand image are considered as significant barriers to entry for new players.

The private industry, in which CUF operates, represents 35.3% out of total expenditure on healthcare in Portugal in 2024 (Data Source: INE - Satellite Account for Health, latest data available). The health private sector shows favourable growth perspectives due to demographic ageing (population aged 65 or over represented 23.3% in Portugal). In addition, life expectancy continues to increase progressively, being estimated at 81.17 years in 2021-2023 (80.96 years in 2020-2022; latest INE data FY 2023). Also, the number of health policyholders shows a steady growth (+3.3% YoY) representing approx. 35% of total population (source: APS 2025). Despite all this, the sector is dependent on the macroeconomic situation and its impact on families' disposable household income for private healthcare services.

• The health sector has medium-to-low ESG exposure.

The healthcare equipment and services sectors have medium to low ESG risks under our methodology (sector heatmap score between 2 and 3). This results in a sector assessment which is not impacted by industry-related considerations. Regarding environmental factors, the sector has a low impact on climate and resources. It has a medium impact on pollution linked to waste, which creates issues on nature and biodiversity. However, healthcare is critical for consumers, which imposes significant responsibilities on the industry. In particular, equal access to medication remains a significant issue. On the financial materiality side, on some occasions expensive lawsuits can affect the business. In addition, health is a major item in the budget for all countries and is also contributing to job creation in many regions. 

Competitive Positioning

• Robust competitive advantages in Portugal, based on its long track record, brand recognition and state-of-the-art technology and equipment.

CUF has a leading position within the private healthcare sector in Portugal, representing approx. 9% of the total private healthcare expenditure (based on total private expenditure on healthcare in 2024, latest information available. Source: INE). This reference positioning is based on its long track record (more than 70 years), which provides it with strong expertise in the sector, its brand, which is highly recognized within the industry, and state-of-the-art technology and equipment, which enables CUF to provide high-quality services. Additionally, the group has an integrated network of high-performance units, which enables the group to offer its wide range of services throughout the main cities of Portugal.

CUF concentrates its business in the healthcare segment, offering a quality private healthcare service as an alternative to the public system. In 2025, the group’s network included 44 units among hospitals, clinics and health centers, distributed according to the area and target population. In addition, the group offers its services via digital channels or conveniently at home. 

The group’s evolution has been characterized by an expansion of the range of services (consultations, exams, permanent care, surgeries, home hospitalization, vaccination, etc.) offered across all areas of care (cardiology, endocrinology, nutrition, urology, psychiatry, etc.), as well as an increase in its network and the use of advanced technology. This has enabled the group to stand out in terms of quality of services (prevention, diagnosis and treatment) and efficiency. For example, the group is currently recognized for having the largest private cancer care network in the country and a leading diagnostic hub. 

In 2025, CUF received several awards reflecting its established brand recognition and reputation within the Portuguese healthcare sector. For the tenth consecutive year, the company was awarded the Marca de Confiança distinction in the “Private Clinics and Hospitals” category, highlighting the strong level of trust and credibility associated with the CUF brand among Portuguese consumers. CUF also received the Marketeer Award, further supporting its positioning as a leading healthcare brand in Portugal, and was recognised by the Randstad Employer Brand Research as the most attractive company to work for within the sector. In addition, CUF was awarded the “Best Health Project” distinction at the 10th edition of the Portugal Digital Awards for its “AI in Clinical Imaging” project. The initiative aims to assess and implement artificial intelligence solutions in real-world healthcare settings, with a view to improving the speed and accuracy of diagnoses, while also enhancing the efficiency and quality of clinical processes.

Although CUF is positioned as the leading player in terms of sales, another noteworthy operator in the private market is Luz Saúde, with a combined market share of approximately 17% of total. CUF’s EBITDA margin stands above that of its main competitor (avg. of 16.6% over the last three years), reflecting the positive management of the group’s cost structure. In terms of financial structure, both competitors show high indebtedness levels on average (above 3.0x over the last three years) characteristic of intensive acquisition programs in a sector that tends towards concentration. CUF’s financial position at end-2025 was weaker due to lower financial autonomy (equity/TFD of 41.9%) and lower coverage ratio (EBITDA/interest of 5.3x).

1 Financial debt adjusted considering estimated non-recourse factoring and acquisition debt.

• Strong diversification of services and clients.

In 2025, CUF divided its activity into three geographical clusters in order to coordinate hospitals’ activities from the three largest hospitals: Norte, Tejo and Descobertas. The most relevant cluster in terms of financial performance is ‘Tejo’ generating 42.5% and 47% of sales and EBITDA of 2025, respectively. 

Diversification by cluster and hospitals FY25

Despite the concentration through its three largest hospitals (CUF Descobertas, CUF Tejo and CUF Porto account for 57.6% of sales in 2025), the ample range of specialties (from cardiology to psychiatry) combined with specific centers (odontology, ophthalmology, etc.), ancillary services (such as laboratory or diagnosis units) and its strategic locations in the main population centers are assessed positively. In addition, the ample portfolio of clinics and the access from anywhere in the country, or even abroad, through remote consultation (proximity care), make the group resilient against potential difficulties in any of the large hospitals. The rest of the hospitals and clinics individually contribute less than 10% of total sales.

Regarding client diversification, CUF shows a well-diversified portfolio composed of individuals, insurance companies, civil servants and other smaller customer groups (state, international entities, etc.). 

Historically, CUF’s geographical footprint has been concentrated in Lisbon and the central and northern regions of Portugal. However, the integration of Grupo HPA Saúde significantly enhances the geographical diversification of the group’s network, expanding its physical presence into the Algarve, Alentejo and Madeira, regions where CUF had no prior presence. As a result, the acquisition strengthens CUF’s nationwide coverage and creates a more balanced geographical footprint across Portugal.

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Shareholder Structure and Governance

• Family ownership structure with strong financial capacity.

As of December 31, 2025, the capital was held by the following entities:

The ownership of the group is concentrated in the hands of the Mello family (through its investment vehicle José de Mello Capital S.A), which controls 65.85%% of the share capital of CUF S.A and stands out as one of the biggest industrial groups in Portugal. The other significant investor is the Association of pharmacies, Farminveste S.A with a 30.0% of the sharecapital, a key player in healthcare in Portugal.

•   Professionalized management team.

We positively value the commitment in day-to-day management and the extensive professional background of the members of the management team. Regarding the group’s financial policy, although it is marked by relatively high indebtedness levels (adjusted NFD/EBITDA of 4.0x on average) and low financial autonomy (adjusted equity/TFD of 40% on average) given its investment plan, this is expected to consolidate an even more robust network of hospitals and clinics, strengthening its current market share. In addition, the group’s strong asset portfolio is viewed positively, as assets could be monetized under a stress scenario. 

• Positive ESG policy. 

The group’s strategy already incorporates and manages ESG issues, leading to a low probability of an ESG-related impact on revenues, results, cash flows, asset value or reputation. We highlight that the group’s governance policies stand out, marked by a qualified board of directors including the presence of independent members, separation of the roles (CEO and Chair of the Board/Supervisory Board), public disclosure of policies (Business Code of Conduct and Corruption Policy) and prioritization of ESG issues. This assessment (score between 1.0 and 1.5) results in a positive impact on the financial profile (+0.5 notch). Also, social and environmental policies stand out with the presence of responsible purchasing policies, gender diversity, HSS management system, low accident and absenteeism rates, good use of energy resources, among others.  

Financial Risk Profile        

The analysis is based on CUF SGPS’s consolidated annual accounts for year-ended 31 December 2025, audited by Deloitte & Associados, SROC S.A. with an unqualified opinion; together with draft financial accounts for the first half of 2026.

Sales and Profitability

• Strong revenue growth and stable profitability, with a favourable medium-term outlook. 

The group’s revenue reached €936.4m in 2025, up 8.9% YoY. Revenue growth was primarily driven by higher medical activity across the group, reflected in increased revenue from consultations (+15.0%), deliveries (+10.3%), surgeries (+9.1%), hospitalizations (+7.8%) and emergency services (+2.8%). Growth also benefited from the full-year contribution of acquisitions completed in 2024, including miMed, acquired in October 2024, which added 12 CUF Health Centers in the Greater Lisbon area.

EBITDA reached a record €170.4m in 2025, up 9.6% YoY, while the EBITDA margin remained broadly stable at 18.2%. EBIT increased by 8.2% YoY to €98.9m, while the EBIT margin remained also stable at 10.6%. Financial expenses increased to €29.8m, +7.1% YoY (2024: €27.9m). EBT increased by 7.5% YoY, to €70.4m.

In the first half of 2026, total turnover increased by 24.8% year on year, supported by the inclusion of Grupo HPA Saúde from February. EBITDA rose to €110.5m, with the EBITDA margin of 18.9%. Financial expenses increased by 14.5% due to higher financial debt. Nevertheless, strong business performance drove EBT to €52.2m, 24.7% above the level recorded in the same period last year.

The outlook for 2026 remains favourable, supported by a combination of organic and inorganic growth, including the acquisition of Grupo HPA Saúde. Sales are forecast to reach €1.2bn in 2026, with 48.8% of the full-year target already achieved by June 2026. Revenue is subsequently projected to grow by 7% in 2027 and 6% in 2028. Profitability margins are expected to remain broadly stable over the forecast period, with the EBITDA margin ranging between 17% and 18% in 2026-2028.

Leverage and Coverage

• Controlled indebtedness level.

CUF SGPS Group’s debt is mainly composed of lease liabilities related to the rental of properties used by its hospital units and equipment. CUF SGPS S.A. has rental agreements with CUF Investimentos Imobiliários S.A., CUF S.A.’s real estate subsidiary, covering healthcare facilities in which the group operates its private healthcare business.

Adjusted total financial debt increased by 12.5% YoY, mainly driven by the issuance of new commercial paper, with the outstanding amount rising to €74.1m at FY25 from €14.7m at FY24. However, the stronger cash and short-term investments of €271.1m, compared with €210.3m in the previous year, supported by the repayment of €50m of loans granted to the shareholder, limited the increase in adjusted net debt to 3.4% YoY. This, together with the positive operating performance reflected in EBITDA growth of 9.6% YoY, resulted in broadly stable leverage, with adjusted NFD/EBITDA at 2.3x in 2025 compared with 2.4x in the previous year. The interest coverage ratio also remained stable at 5.7x in 2025.

As of June 2026, adjusted NFD had increased to €547.6m, mainly reflecting additional debt raised in connection with the acquisition of Grupo HPA Saúde. Consequently, leverage increased, with adjusted NFD/EBITDA rising to 2.6x from 2.3x at year-end 2025. Conversely, LTM EBITDA/interest coverage improved further to 6.0x, supported by stronger EBITDA generation, while the interest expense associated with the new debt had not yet been fully reflected.

1 Includes other financial instruments €151.1m (June-2026), €220.1m (2025), €109.4m (2024) and €65.7m (2023) relating to the group contract for joint treasury management of the CUF Group with a financial institution. In addition, a loan to the shareholder CUF, S.A., in the amount of €50m was included as part of short-term investments in 2024. This loan was recovered in the first half of 2025. 2 Estimated EBITDA FY26 with the purpose of including Grupo HPA Saúde. 3 Estimated by EthiFinance Ratings.

Looking ahead, leverage is expected to increase slightly by year-end 2026, before gradually improving over the following years, supported by EBITDA growth, although remaining at controlled levels. Interest coverage is also expected to moderate, reflecting higher debt levels and financing costs.

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Cash Flow Analysis

• Growing and positive FFO on the back of the increase in EBITDA.

1 Estimated by EthiFinance Ratings. 2 Includes other financial instruments: €81.6m (2025), €109.4m (2024) and €65.7m (2023) relating to the group contract for joint treasury management of the CUF Group with a financial institution. This allows immediate liquidity up to the contractual limit, without risk of change in value. Excludes overdraft facility.

CUF Group reported a 10.4% YoY increase in FFO in 2025, supported by stronger EBITDA generation (+9.6% YoY). Operating cash flow stood at €127.7m, down 6.6% YoY, following a positive working capital variation of €2.4m.

Cash flow from investing activities stood at -€178.6m in 2025, compared with -€106.5m in 2024. This amount includes -€138m related to the joint treasury account with the shareholder, CUF, S.A. During the year, CUF continued to invest in expansion, infrastructure and information systems. It also completed the acquisition of S.P.S.I. – Sociedade Portuguesa de Serviços de Apoio e Assistência a Idosos, S.A. (SPSI) for €3.4m. These investments, together with dividend payments of €36.9m, resulted in negative internally generated CF of -€125.2m. The +€97.5m debt variation helped limit the decline in cash to €27.7m, resulting in a final cash position of €132.6m (-17.3% YoY).

Looking ahead, CFO generation is expected to remain solid over 2026-2028, supported by increasing FFO. However, the group’s substantial investment program and dividend payments to the parent company are expected to constrain internally generated CF, particularly in 2026.

Capitalization

• Strong financial autonomy.

At the end of November 2021, an internal reorganization was carried out to centralize the management of the shareholdings in the companies that manage and operate the private healthcare units under a sub-holding company, CUF SGPS S.A. This operation involved capital contributions of €953.9m, which were used to acquire the shares of the private healthcare companies. As a result, goodwill now represents 49.2% of total assets and is mainly related to Hospital CUF Descobertas S.A. (€233.7m), Hospital CUF Tejo S.A. (€224.7m), Hospital CUF Cascais S.A. (€133.5m) and Hospital CUF Porto S.A. (€103.7m). Right-of-use assets represented 19.0% of total assets (€344.5m) at end-2025. The remaining assets mainly comprise PPE, financial investments, receivables and inventories.

Equity remained relatively stable at €986.2m (+1.4% YoY), despite a €36.9m dividend payment to the parent company, CUF S.A. By contrast, total financial debt increased by 12.5% YoY, resulting in lower financial autonomy, although capitalization remained strong, with equity equivalent to 148.6% of adjusted total financial debt in 2025.

As of June 2026, the group’s capitalization ratio declined to 142%, following the increase in financial debt mainly associated with the acquisition of Grupo HPA Saúde.

Looking ahead, capitalization is expected to remain strong, with equity representing around 130% of adjusted total financial debt on average over the period 2026-2028.

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Liquidity

• High level of liquidity with a satisfactory refinancing profile.

CUF Group maintains an adequate capacity to meet its short-term financial commitments, supported by stable and recurring operating cash flow generation. The group also benefits from a satisfactory financial profile, providing additional flexibility to raise new debt or refinance existing instruments, if required.

The acquisition of Grupo HPA Saúde was completed during the first half of 2026, financed through a combination of new debt financing and the deployment of excess cash accumulated over the previous two years. CUF had been progressively building up its liquidity position in anticipation of the transaction. Consequently, the acquisition has not resulted in material additional pressure on the group’s liquidity position.

Modifiers

Controversies

• The group has an administrative offence proceeding raised by the Portuguese Competition Authority (AdC). CUF remains involved in an ongoing competition proceeding related to alleged anti-competitive coordination with other private hospital groups in negotiations with ADSE. The AdC initially imposed a fine in 2022, which CUF appealed. In April 2024, the court annulled the AdC’s decision on procedural grounds and returned the case to the investigation stage. In June 2025, the AdC issued a new statement of objections, with a maximum potential fine for CUF of approximately €89m. CUF contests the allegations and is awaiting the AdC’s final decision, which remains subject to judicial appeal. No provision has been recognized in relation to the proceeding.
• On 31 December 2025 there were lawsuits brought against the group. The group estimates that the liability not covered by the insurance it has contracted amounts to approximately €21.41m (FYE24: €25m). However, the group maintains a provision in its accounts for an amount that the management considers a reasonable estimated risk exposure. No further information is available based on the financial statements as of December 2025.

The above controversies, although monitored by EthiFinance Ratings are considered manageable and therefore to have a neutral impact on the rating (Controversial ESG score between 1 and 3).

Country Risk

• No country risk has been identified. 

Main Financial Figures 

CUF SGPS S.A 

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CUF S.A

1 Financial debt adjusted considering estimated non-recourse factoring and acquisition debt.

Credit Rating

1Final rating is capped by the credit rating of CUF SA.

Rating Sensitivity

At consolidated level, CUF S.A.:

• Long-term rating positive factors (↑)

A favourable economic context, materializing in rising demand for private healthcare services, together with the successful integration of newly opened units, could enhance CUF’s financial metrics. As a guidance, the improvement in adjusted indebtedness levels (NFD/EBITDA below 3.5x, FFO/NFD above 20% and EBITDA/interest above 5.0x), greater financial autonomy (equity/TFD above 50% on average) and/or ESG group score between 0 and 1 corresponding to the best ESG grading could enhance the rating.

• Long-term rating negative factors (↓)

A less favourable macroeconomic environment, reducing households’ purchasing power and demand for private services, would pose downside risks. The group could also be pressured by rising labour costs, as well as by potential delays or inefficiencies in integrating new hospital units. Also, increasing competition in the private healthcare sector, particularly from other established hospital groups, may weigh on pricing power and profitability margins. As a guidance, a deterioration in adjusted indebtedness levels (NFD/EBITDA above 4.5x, FFO/NFD below 10% and EBITDA/interest below 4.0x on average), decreased financial autonomy (equity/TFD below 30% on average) , a weaker ESG assessment and/or the materialization of any material controversy could negatively affect the current rating.