Painel Abramed 2021 - O DNA do Diagnóstico - inglês

Annual Publication | n 4 ABRAMED PANEL The DNAof Diagnostics 2021

Abramed Highlights $ Revenue GrossRevenue ofthe Diagnostic Medicine Market 2020 Supplementary HealthCare Abramed 32,1 BILLIONS 13,9 BILLIONS 2021 35,1 BILLIONS 16,1 BILLIONS ESTIMATE Expenditures $ Total assitential expense in supplementary healthcare 2020 165,8 Share of Examinations Expenditure BILLIONS 20,8% 19,4% 21,1% 2021 193,8 2019 2020 2021 ESTIMATE BILLIONS Jobs (2020) The diagnostic medicine sector was responsible for maintaining 12% 275,7 84,4 THOUSAND THOUSAND of healthcare jobs are in the field of Workstations People employed by diagnostic medicine. Abramed Member Companies Market Share (2020) ShareofAbramedmembersinthevolumeofexamsperformed 70,6% 29,4% 58,9% 41,1% Abramed Total on Other Labs Others in Brazil Abramed Total Supplementary HealthCare in Brazil 2021 900,5 532,8 915,7 ESTIMATE MILLIONS MILLIONS MILLIONS Supplementary Abramed Members SUS HealthCare Procedures with diagnostical purposes (2020) 783 461,6 785,6 MILLIONS MILLIONS MILLIONS Supplementary Abramed Members SUS HealthCare NOTE: 2021 CONSIDERS THE FIRST SIX MONTHS OF THE YEAR.

Revenue Sources Facilities Patients (2021) (2021) In 2021 the member companies served 54,3% from Abramed Member Companies have: more than 36 million patients HealtCare Plans 469 Imaging 37,2% 62,8% Centres Men Women 24,3% Lab to lab 83 Execution 15,2% Private Centres No Show Rate 5,3% Public 275 Labs inside 16,3% (2021) Hospitals 1.754 Collection Sites Acess Claims and Average Quality (2021) Term (2021) Management 17,8% Average percentageofmonthlydisallowance 96,2% of the exams 3,8%Initial Average percentage were retrieved 2,1%Final of doctors or accessed over 1,7%Unpaid with specialist the internet qualifications Average collection period for in the member 4,1% health insurance companies companies of exams were not 34 to 53 days accessed at all Investments Equipments Customer (2021) (2021) Satisfaction 4,2% Diagnostic imaging Net Promoter Equipments in 2019 Score of revenue (NPS) in Investments 2.815 80,6% Distributed mainly in: (2021) Machinery and equipments, real estate and renovations, and R&D

007 Administrative Council 008 Letter to the reader 010 Abramed 1 017 POPULATION AND DEMOGRAPHICS 018 Population 028 Population projection 030 Demographics 030 Populacional ageing 034 Necessary tests for a quick and accurate diagnosis - Chronic non-communicable diseases 041 Fertility, birth and mortality rates 042 Life expectancy at birth 044 Mortality and morbidity 2 050 ECONOMIC ENVIROMENT 057 Economic Activity 062 Labor Market 3 069 BRAZILIAN 083 Expenses with SUPPLEMENTARY HEALTH complementary exams MARKET 088 Beneficiaries 072 Operators 095 Distribution per region and 076 Economic and financial population size performance 098 Coverage Rate 078 Accident Rates 104 Hospitals and Hospital beds 080 Average Payment Period 108 Medical Demographics 082 Health promotion and 111 Total Health Expenditure prevention of risks and 116 Incorporation of diagnostic diseases procedures

summary 4 121 THE DIAGNOSTIC MEDICINE SECTOR 124 Ancillary Service of Diagnosis and Therapyand Diagnostic Support Units 135 Trends and challenges in the diagnostic medicine market 144 Diagnostic Imaging Equipments 157 Doctors acting in diagnostic medicine 160 Labour market in the sector of diagnostic medicine 164 Supplementary Health 170 Early Diagnosis 172 Unified Health System (SUS) 5 179 COVID-19 180 Pandemic X-Ray 182 The diagnostic medicine sector’s role 184 Epidemiological profile 192 The diagnosis of Covid-19 203 Preventive measures 205 Impacts on the diagnostic medicine sector 212 The Regulatory Agencies’ role 214 The use of health insurance 6 224 ABRAMED PANEL 279 ABRAMED 225 Institutional Profile ASSOCIATED 237 Human resources COMPANIES 244 Assistential production 253 Service Evaluation 258 Economic-financial performance 267 Corporate governance 273 Work Methodology 274 Bibliography

Editor Wilson Shcolnik | Chairman of the Abramed Administrative Council | Abramed Abramed Council Ademar Paes Júnior | Clínica Imagem Cesar Nomura | Hospital Sírio-Libanês Claudia Cohn | Dasa Eliezer Silva | Sociedade Beneficente Israelita Brasileira Albert Einstein Leandro Figueira | Alliar Médicos À Frente Lídia Abdalla | Sabin Medicina Diagnóstica Wilson Shcolnik | Grupo Fleury Content and Editing Álvaro Almeida | Abramed Project Management Juliane Trevisan | Mf Marketing & Business Advisor Graphic Design Laika Design Photography Shutherstock, Pexel and Unsplash Printing Fly Print

Administrative “The Abramed Panel has Council become a reference in data intelligence to this sector. “The Abramed Panel has The publication is a valuable become a reference of quality consultation tool that helps data and information. institutions make more Important for strategic decision assertive decisions.” making”. Ademar Paes Júnior Cesar Nomura CLÍNICA IMAGEM HOSPITAL SÍRIO-LIBANÊS “ It is one of the achievements of which I am most proud “The consolidation of the to have built along with the data offered in the Diagnostic associates, the Abramed Panel DNA provides relevant is now anticipated by the information that can support healthcare segment. It offers companies’ planning, as well a broad, clear and accessible as demonstrating the social view of the diagnostics sector, impacts of sectoral activity.” and enables evaluation of Eliezer Silva impacts that allow us to build the bridges for the future of SOCIEDADE healthcare in Brazil.” BENEFICENTE Claudia Cohn ISRAELITA BRASILEIRA ALBERT EINSTEIN DASA “We finished 2021 with a “The Abramed Panel is a sense of accomplishment. consistent work that has earned We saw the evolution and the society’s respect. Nowadays, unquestionable value of citing data from the Panel gives diagnostic medicine, which, unequivocal credibility to the without a doubt, was a major texts and their authors.” player in the face of adversity Leandro Figueira to deliver health and quality of life to the population. We had ALLIAR MÉDICOS an intense year of learning, À FRENTE which strengthened us to begin this new cycle even more “Overcoming all the challenges united and prepared for new brought on by the pandemic, challenges, many discoveries with this publication Abramed and great achievements”. demonstrates the importance Lídia Abdalla of diagnostic medicine, which is becoming increasingly SABIN MEDICINA professional, modernized and DIAGNÓSTICA fulfilling its role in offering services that contribute to the betterment of Brazilian health care.” Wilson Shcolnik GRUPO FLEURY ABRAMED ABRAMED PANEL 7

Letter to the reader ALMOST TWO YEARS AGO WE WITNESSED THE BEGINNING AND CONSEQUENTIAL DISSEMINATION OF COVID-19, WHICH REACHED ALL 5,570 MUNICIPALITIES IN THE COUNTRY, WITH UNPRECEDENTED IMPACTS ON THE COUNTRY’S HEALTH SYSTEM. Since then, the high quality and accurate has been the pillar of the rise in quality and covid-19 detection tests were essential to life expectancy of the population in recent contain and manage the pandemic’s progress decades. Life expectancy at birth has shown in Brazil and in the world, together with the significant gains thanks to the medical development and progress of vaccination developments, and this is unquestionable. of the population. Only by testing people it was possible to decide which actions The rejection of the basic principles of should be taken and, mainly, to improve scientific work should not be substituted the management of the population’ s health. by controversial and refutable ideals, that In this sense, the Abramed members have jeopardize the population’ s health. On increased the offer and capacity to perform the contrary, in the diagnostic medicine tests and process samples sent to the sector, for example, the emergence of new Reference Laboratories. technologies has a positive influence on the quality, speed and accuracy of diagnosis, We have been coexisting with one of considerably increasing the chances of the worst evils in facing the disease: the controlling and curing innumerable diseases. negationism and the discrediting of the value of science in the clinical management Diagnostic laboratory and imaging tests have of patients. Nevertheless, the indication of played a key role in the patient’s cycle of care treatments with no evidence of effectiveness, for many decades, and recently, and this has the encouragement against social isolation been reinforced in dealing with covid-19 in measures and the discouragement to use the country. The ability to detect the virus masks characterized the unfolding of the was essential in determining whether a pandemic in the country. The scientific person was infected, and many other tests and technological development observed helped in indicating and managing clinical in the health sector, among other factors, treatment, as well as being able to guide 8 ABRAMED PANEL ABRAMED

case management and support the isolation indicators that help to further highlight the measures needed to prevent a more rapid importance of the diagnostic medicine sector spread among the population. in the patient care cycle. Since the pandemic broke out, the sector has It is essential to acknowledge all those who worked on the development of molecular have supported us and collaborated with tests recommended by the World Health the development of the sector throughout Organization (WHO). Imaging exams, such this journey: the scientific societies, essential as CT scans, were also essential to diagnose partners in our work, represented here by the and monitor the most severe cases that Brazilian College of Radiology and Diagnostic entailed respiratory failure, along with other Imaging (CBR); the Brazilian Society of laboratory tests. Continuously, numerous Clinical Analysis (SBAC); the Brazilian actions were taken to improve diagnostic Society of Pathology (SBP); the Brazilian methods and facilitate access for the Brazilian Society of Clinical Pathology and Laboratory population. The cooperation of the various Medicine (SBPC/ ML); the Paulista Society of agents was essential for the advancement and Radiology (SPR); as well as other entities and consolidation of the measures necessary to autarchies representing the health sector. deal with the pandemic. I thank the members of our Administrative Despite the complex and challenging Council for their diligence and guidance in the outlook, in 2020 and 2021, the diagnostic search for the fulfillment of our institutional medicine sector continued to invest in new mission. I also thank Abramed’s employees for technologies and modes of service to offer their commitment and the results achieved in laboratory diagnosis and imaging solutions, the last year. further accelerating digital transformation, process automation, the use of artificial Wilson Shcolnik intelligence technologies and the Internet of Chairman of the Abramed Administrative Things, among many others, always aiming Council to provide excellent services that contribute to greater health care. 9ABRAMED ABRAMED PANEL The “Abramed Panel - The DNA of Diagnosis” strengthens its commitment to the transparency within the sector, and in its 4th edition presents an exclusive overview of the diagnostic medicine sector in Brazil. In each edition, we introduce new content and sector

Abramed ABRAMED REPRESENTS LEADING INSTITUTIONS IN THE DIAGNOSTIC MEDICINE MARKET, RECOGNIZED FOR THE HIGH QUALITY OF THEIR SERVICES, TECHNOLOGICAL INNOVATION AND EXCELLENCE IN MARKET MANAGEMENT PRACTICES, GOVERNANCE, COMPLIANCE AND CORPORATE RESPONSIBILITY. ITS ACTIVITIES ARE GUIDED BY PRINCIPLES THAT ARE CONSISTENT WITH LEGAL, TECHNICAL AND ETHICAL STANDARDS. ABRAMED’S PILLARS ARE: 10 ABRAMED PANEL ABRAMED

Ensure to focus on the pacient care. To exercise dialogue Influence the market and exchange techncal, to uphold ethical and scientifc and management transparent behavior. knowledge with associated companies and other players in the health chain. Engage in dialogue and Protect the interests of the establish positive agendas associates, always within with the sector’s scientific the framework of an ethical societies. conduct and the best practices in compliance. To represent the diagnostic Act in an objective and medicine segment before cohesive manner in themes governmental and regulatory related to supplementary bodies. health in Brazil, contributing to its continuous improvement. 11ABRAMED ABRAMED PANEL

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Ethics and Abramed Understanding the literal meaning of the Abramed is word ethics - from the Greek ethos, it means committed to “custom”, set of principles, moral values and transparency conduct of an individual or social group or and sector-wide society - the understanding seems simple integrity. when applied to any segment, including health, in which all players in the sector should To this end, Abramed, committed to the use practices that provide the achievement ethical issues of all those involved in the health of excellence of care and maximum patient production chain, has created important tools safety. that contribute to supporting and monitoring compliance of practices that are primarily in Achieving a solid commitment to the interest of patients, by holding debates on transparency and integrity in a segment with this topic in its forums. complex, not always synergic interactions between the public and private sectors, as 13ABRAMED ABRAMED PANEL well as unequal information among providers, financers, and users, requires the adoption of habits that keep companies and institutions in compliance with laws, rules, and regulations and, above all, with the values conveyed in their mission. Regarding the sector, compliance practices in the diagnostic medicine segment contribute to a fairer and more sustainable market, with ethical and long-lasting companies that generate better results in health care for the population.

Abramed Initiatives Ethics Committee With the objective of incentivizing the diagnostic medicine sector to adopt policies and procedures that ensure ethical conduct and compliance with legal norms, Abramed created its Ethics Committee, which guides and approves compliance policies and guidelines within the association, as well as investigating any reports of violations. Code of Complaints Conduct Channel The first code of conduct for the diagnostic The exclusive channel (www.canaldedenuncia. medicine sector, released by Abramed in com.br/abramed) for secure and anonymous 2017, the publication advises, encourages, and communication of actions that violate the demands from its members behaviors and Code of Conduct, Abramed’s good practices practices that inspire all links in the chain, or the applicable legislation. The complaints directly contributing to health institutions are forwarded to the Ethics Committee for taking responsibility for practices and analysis and deliberation of referral, which the provision of qualified information to may include advising the associate, or even, their patients, thus stimulating the desired in more serious cases, punitive measures to be outcomes of health care. defined through partnerships with specialized entities. 14 ABRAMED PANEL ABRAMED

Compliance Compliance practices in Guidebook - Good the diagnostic Practices Guide medicine segment for the Diagnostic contribute to a Medicine Sector fairer and more sustainable market. Competitive The most recent initiative of the institution, Practices the guidebook was developed so that Regulation associated and other companies in the diagnostic medicine sector have simplified Set of norms that clarify to the Association’s and objective information about the process collaborators and its associates what can of creating a compliance program, where to be discussed and how to deal with sectorial start and which points should be worked on. matters in the context of the association, also pointing out themes that cannot be Governance, approached, such as information that is Ethics and competitively sensitive. Compliance Committee Antitrust Rules of Procedure Formed by members of the associated companies, the purpose of the group is to Rules to protect associates from antitrust discuss and evaluate actions aimed at the legislation. dissemination, qualification and training of codes, standards, and ethical issues in the diagnostic medicine sector. 15ABRAMED ABRAMED PANEL

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Population and Demographics 01 17ABRAMED PANEL

01.1 POPULATION IN MARCH 2020, THE WORLD HEALTH ORGANISATION (WHO) DECLARED A PANDEMIC OF COVID-19, A DISEASE CAUSED BY THE SARS-COV-2 VIRUS. At the time, about 150,000 people had been 213.3 million inhabitants2 and maintains a infected and 4,600 deaths were reported. decelerating growth rate that began in the Approximately a year and a half after the 1960s. Since then, the geometric average beginning of the pandemic, global numbers growth rate fell from 3.04% at the end of the indicated more than 226 million infected and 1960s to 1.02% at the end of the last ten years, 4.7 million deaths1. Besides the epidemiological registering the lowest variation recorded and sanitary aspects, the pandemic caused since the beginning of the historical series in several social and economic changes, 1872. According to the Brazilian Institute of among others, especially in population and Geography and Statistics (IBGE) “the effects demographic projections. Population data of the covid-19 pandemic on the population rarely present significant short-term variations, contingent were not incorporated, due to especially between one year and another. the absence of new migration data, besides the need for consolidation of mortality and The Brazilian population has grown more fertility data, which are fundamental for than seven times in the last hundred understanding the demographic dynamic years. In 2021, it will total approximately as a whole”. 1 Covid-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Extracted on August 1st, 21. 2 IBGE/Diretoria de Pesquisas. Coordenação de População e Indicadores Sociais. Gerência de Estudos e Análises da Dinâmica Demográfica. Estimates of the resident population in Brazil and states of the Federation with reference date on July 1st, 2021. 18 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

The Brazilian population grew more than 7 times in the last hundred years. GRAPH POPULATION (IN MILLIONS) AND ANNUAL GROWTH RATE - BRAZIL (%–1960/2021) 1 SOURCE: IBGE. DIRETORIA DE PESQUISAS - DPE - COORDENAÇÃO DE POPULAÇÃO E INDICADORES SOCIAIS - COPIS. EXTRACTED ON SEPTEMBER 1ST, 2021. ELABORATED BY ABRAMED 3,04 2,89 2,48 1,98 169,8 190,8 211,8 213,3 70,1 93,1 119,0 144,8 1,60 1,17 1,05 1,02 1960 1970 1980 1990 2000 2010 2020 2021 Population Annual Growth Rate POPULATION AND DEMOGRAPHICS 19ABRAMED PANEL

The covid-19 pandemic impacted vegetative The vegetative population growth in 2020. The data show an growth of the increase in mortality and a sharper reduction in population in 2020 the number of births. In 2021, the country may was impacted record for the first time more deaths than births by the pandemic in a year, with direct impacts on the projection of the new and life expectancy of the population. coronavirus. GRAPH DEATHS AND BIRTHS IN BRAZIL IN MILLIONS (2015/2021) 2 Source: RegistroCivil–PortaldaTransparência.Extracted on 1/8/21. Prepared by Abramed. Note: 2021 considers data available until July 2,8 2,8 2,6 2,4 2,5 2,6 1,5 1,5 0,9 1,0 1,1 1,2 1,3 1,1 2015 2016 2017 2018 2019 2020 2021 Deaths Births This phenomenon was noticed in the states of Rio de Janeiro and Rio Grande do Sul, where the number of deaths was higher than the number of births in the first seven months of 2021. Other more populous states such as São Paulo and Minas Gerais presented a high proportion of deaths. 20 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

TABLE POPULATION, DEATHS AND BIRTHS BY REGION AND STATE (BRAZIL - 2021) 1 Source: IBGE. Research Directorate - DPE - Population and Social Indicators Coordination - COPIS. Prepared by Abramed. Note: ¹Population estimates resident in Brazilian municipalities with reference date on July 1st 2021. Region State Population¹ Births Deaths Balance NORTH Rondônia 18.906.962 158.466 59.183 99.283 Acre 1.815.278 14.067 9.209 4.858 NORTHEAST Amazonas 906.876 9.195 3.606 5.589 Roraima 4.269.995 42.260 16.951 25.309 SOUTHEAST Pará 652.713 6.130 1.881 4.249 SOUTH Amapá 8.777.124 66.542 19.519 47.023 CENTER-WEST Tocantins 877.613 9.049 2.372 6.677 BRAZIL 1.607.363 11.223 5.645 5.578 57.667.842 416.994 236.625 180.319 55.716 20.017 35.699 Maranhão 7.153.262 18.736 9.346 9.380 67.075 40.939 26.136 Piauí 3.289.290 23.658 13.941 9.717 33.152 21.206 11.946 Ceará 9.240.580 71.164 47.470 23.694 26.029 12.995 13.034 Rio Grande do Norte 3.560.903 18.058 9.844 8.214 103.366 60.867 42.499 Paraíba 4.059.905 601.664 538.274 63.390 Pernambuco 9.674.793 143.310 119.628 23.682 31.187 20.841 10.346 Alagoas 3.365.351 110.649 112.996 - 2.347 316.518 284.809 31.709 Sergipe 2.338.474 218.266 182.648 35.618 Bahia 14.985.284 84.716 69.089 15.627 58.073 37.415 20.658 Minas Gerais 89.632.912 75.477 76.144 - 667 Espírito Santo 21.411.923 Rio de Janeiro 4.108.508 218.266 182.648 35.709 São Paulo 17.463.349 25.326 16.018 9.308 46.649.132 31.790 16.516 15.274 45.719 35.579 11.140 Paraná 30.402.587 58.770 13.470 15.300 Santa Catarina 11.597.484 Rio Grande do Sul 7.338.473 1.526.945 1.097.313 429.632 11.466.630 16.707.336 Mato Grosso do Sul 2.839.188 Mato Grosso 3.567.234 Goiás 7.206.589 Distrito Federal 3.094.325 213.317.639 POPULATION AND DEMOGRAPHICS 21ABRAMED PANEL

The country’s population is distributed This irregularity in distribution imposes a huge irregularlythroughouttheterritory,considering challenge in access to health services due to the historical aspects, especially those associated existence of several isolated locations, lacking with the socioeconomic development of the minimum infrastructure necessary for the each region. In the Southeast, 89.6 million maintenance, economic and financial viability inhabitants are registered, representing of these services. These are the so-called “care 42% of the population, distributed in 1,668 voids” municipalities. In the Northeast there are 57.7 million inhabitants, with 27% of the population distributed in 1,794 municipalities. These two regions concentrated more than two thirds of the country’s population in June 2021, while the other regions, South, North and Center-West, concentrated 30.9% of the population in 2,108 municipalities of the country. TABLE DISTRIBUTION OF THE RESIDENT POPULATION, MUNICIPALITIES AND POPULATION DENSITY ACCORDING TO REGION (QUANTITY AND PERCENTAGE DISTRIBUTION - 2 BRAZIL -2021) Source: IBGE. Diretoria de Pesquisas - DPE - Coordenação de População e Indicadores Sociais - COPIS. Abramed elaboration. Note: ¹Population estimates resident in Brazilian municipalities with reference date on July 1st, 2021. Region Population1 Distribution % Municipalitie Distribution % Density Centre-West 16.707.336 7,8 467 INHABITANTES PER KM2 Northeast 57.667.842 27 1.794 North 18.906.962 8,9 450 8,4 10,4 Southeast 89.632.912 42 1.668 South 30.402.587 14,3 1.191 32,2 37,2 Brazil 213.317.639 100 5.570 8,1 4,9 29,9 96,9 21,4 53,9 100 25,1 The occupation of municipalities in the the economic activity and the most labor- country is concentrated mainly in coastal intensive sectors. While the other inland areas (dark areas on the map), extending areas are less densely populated, being approximately 520 Km inland. These were occupied essentially by less labor-intensive the first areas occupied at the beginning activities, such as farming, livestock raising of the country’s colonization process and, and mining. since then, they have concentrated most of 22 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

MAP POPULATION DENSITY PER MUNICIPALITY (BRAZIL - 2021) 1 Source: IBGE. Elaborated by Abramed. Population density (inhabitants per km2) Up to 5 5 – 10 10 - 15 15 - 20 20 - 25 25 - 30 30 - 45 45 - 70 70 - 150 > 150 POPULATION AND DEMOGRAPHICS 23ABRAMED PANEL

At the beginning of the covid-19 pandemic, Health service demographic density had been mistakenly availability is pointed out as an important variable in the unequal and dissemination of the virus in densely populated regionalized. municipalities. However, it turned out that peripheral and low-income regions were much more vulnerable to the pandemic, so density would have little impact on the spread of the coronavirus. Socioeconomic, demographic and health infrastructure factors have an influence on the higher risk of disease progression. The organization and offer of health services in Brazil is regionalized and depends essentially on economies of scale to enable the existence of a health care network. These economies are directly associated, among other factors, with the population size of the municipalities. In this sense, it is observed that most of the country’s municipalities (3,770 - 67.7%) have up to 20,000 inhabitants and contain 14.8% of the population, corresponding to 31.6 million inhabitants. The following map illustrates in the darkest areas the municipalities with up to 20,000 inhabitants, and in the lightest areas the municipalities with population above 20, 000 inhabitants. 24 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

MAP MUNICIPALITIES WITH UP TO 20 THOUSAND INHABITANTS (DARK AREAS ON THE MAP) AND ABOVE 20 THOUSAND INHABITANTS (BRAZIL - 2021) 2 Source: IBGE. Diretoria de Pesquisas - DPE - Coordenação de População e Indicadores Sociais - COPIS. Prepared by Abramed. Note: Estimates of the population living in Brazilian municipalities with reference date on July 1, 2021. Municipalities Up to 20 thousand – 3.770 (67,7%) Over 20 thousand – 1.800 (32,3%) POPULATION AND DEMOGRAPHICS 25ABRAMED PANEL

The other municipalities in the country (1,800 - 32.3%) have more than 20 thousand inhabitants and comprise 85.2% of the population, which represents 181.7 million inhabitants. Another relevant fact is that only 49 municipalities (0.9%) account for 31.9% of the population, equivalent to 68 million. These disparities in population distribution accentuate the differences in the availability of health services. In this sense, the provision of diagnostic medicine services in municipalities with up to 20 thousand inhabitants corresponds to 13.5%. TABLE DISTRIBUTION OF THE RESIDENT POPULATION AND MUNICIPALITIES ACCORDING TO INHABITANTS’ BRACKET (QUANTITY AND PERCENTAGE 3 DISTRIBUTION - BRAZIL - 2021) Source: IBGE. Diretoria de Pesquisas - DPE - Coordenação de População e Indicadores Sociais - COPIS. Prepared by Abramed. Note: ¹Population estimates for Brazilian municipalities with reference date on July 1st, 2021. Inhabitants Population % % Accumulated Municipalities % % Accumulated Up to 5.000 4.184.620 22 1.250 22,4 22,4 46 1.201 21,6 44 From 10.001 to 20.000 8.576.898 8,8 14,8 1.319 23,7 67,7 16 30,8 1.120 20,1 87,8 From 20.001 to 50.000 18.861.814 11,5 42,8 354 6,4 94,1 25,8 68,1 277 5 99,1 From 20.001 to 50.000 34.172.858 31,9 100 49 0,9 100 100 – 5.570 100 – From 50.001 to 100.000 24.498.937 From 50.001 to 100.000 54.999.084 From 100.001 to 500.000 68.023.428 Brazil 213.317.639 26 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

MAPA DISTRIBUTION OF THE RESIDENT POPULATION BY MUNICIPALITY AND REGION (NUMBER OF INHABITANTS – BRAZIL – 2021) 3 Source: IBGE. Diretoria de Pesquisas - DPE - Coordenação de População e Indicadores Sociais - COPIS. Prepared by Abramed. Note: Estimates of the population living in Brazilian municipalities with reference date on July 1st, 2021. Inhabitants % of municipalities Up to 5.000 22,4 5.001 up to 10.000 21,6 10.001 up to 20.000 23,7 20.001 up to 50.000 20,1 50.001 up to 100.000 6,4 100.001 up to 50.000 5,0 500.001 up to 12 millions 0,9 POPULATION AND DEMOGRAPHICS 27ABRAMED PANEL

01.1.1 Population projections THE POPULATION PROJECTION IN BRAZIL INDICATES A REDUCTION IN THE RATE OF GROWTH AND EACH YEAR THE POPULATION GROWS LESS. The population is estimated to grow until This change in the age structure should not be 2047, when it should reach 233 million. From immediately impacted by covid-19. However, 2048 onwards, geometric growth rates will be new population projections will certainly negative and there will be a population decline, be altered considering the developments of with approximately 228 million inhabitants at the pandemic in the long term. Thus, it is the end of 2060. In this scenario, it is projected estimated an increase in demand for health an increase in the proportion of elderly (60 services, especially in the sector of diagnostic years or older), which represents 14.7% (31.3 medicine, due to demographic changes and the million) in 2021, and should reach 32.2% (73.5 developments of covid-19 in the health status of million) of the population in 2060. the population. GRAPH PROJECTION OF THE POPULATION IN MILLIONS BY AGE GROUPS IN BRAZIL (2010/2060) 3 Source: IBGE/Diretoria de Pesquisas. Coordenação de População e Indicadores Sociais. Gerência de Estudos e Análises da Dinâmica Demográfica. Updated in 04/06/2020. Population projection of Brazil and states by sex and age for the period 2010-2060. Prepared by Abramed. 213,3 228,3 122,4 109,3 75,5 59,6 45,5 31,3 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 60+ 0 - 19 20 - 59 Total 28 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

Population projections will have to be altered considering the unfolding of the pandemic. This trend is present in the use of health services. In 2021, a more accentuated proportion of procedures with diagnostic and surgical purposes is observed in the adult and elderly population. This fact reflects the prevalence of chronic diseases and risk factors associated with these age groups. GRAPH SHARE OF PROCEDURES FOR DIAGNOSTIC AND SURGICAL PURPOSES PERFORMED AT THE SUSTAINABLE SUS IN %, BY AGE RANGE (2021) 4 Source: Ministério da Saúde - Sistema de Informações Ambulatoriais do SUS (SIA/SUS). Prepared by Abramed. 12 10 8 6 4 2 0 <1 1 - 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+ Procedures with Diagnostic Purposes Surgical Procedures POPULATION AND DEMOGRAPHICS 29ABRAMED PANEL

01.2 DEMOGRAPHICS 01.2.1 Population ageing ONE OF THE MOST STRIKING FEATURES OF THE 21ST CENTURY IS CERTAINLY RELATED TO POPULATION AGEING. The United Nations General Assembly, the less developed countries3. In 2011, the elderly main deliberative, representative, and policy- population totalled 513 million, ten years later, -making body of the United Nations (UN), in 2021, it had increased to 749 million. It is declared the period from 2021 to 2030 as estimated to reach about 1.7 billion in 2050 and the Decade of Healthy Ageing. Population account for 79.5% of the elderly population in ageing is a new phenomenon in history, with the world. This fact represents an enormous different developments among nations. socio-economic challenge, among others, considering that a large part of the population The number and proportion of people aged 60 in less developed countries does not become years and over among the population increases rich before ageing, unlike what is observed in every year and at a faster rate, especially in developed countries. 30 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

Population ageing is a recent phenomenon in human history with different developments among nations. TABLE PROJECTION OF THE TOTAL POPULATION, ELDERLY (60+) AND ELDERLY POPULATION SHARE (SELECTED COUNTRIES – 1950/2100) 4 Source: United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Online Edition. Rev.1. Prepared by Abramed. Year Population China India United Japan Russia Brazil World 1950 /Country States 2021 82.802 102.799 2050 Total 554.419 376.325 158.804 6.344 7.891 53.975 2.536.431 2100 60+ 41.108 20.302 19.728 7,7% 7,7% 2.627 202.158 Share 7,4% 5,4% 12,4% 4,9% 8,0% 126.051 145.912 Total 1.444.216 1.393.409 332.915 43.611 33.432 213.993 7.874.966 60+ 258.372 144.322 77.520 34,6% 22,9% 31.044 1.081.903 Share 17,9% 10,4% 23,3% 105.804 135.824 14,5% 13,7% 46.480 41.495 Total 1.402.405 1.639.176 379.419 43,9% 30,6% 228.980 9.735.034 60+ 485.489 319.918 106.904 74.959 126.143 67.361 2.079.639 Share 34,6% 19,5% 28,2% 32.245 38.839 29,4% 21,4% 43,0% 30,8% Total 1.064.993 1.447.026 433.854 180.683 10.875.394 60+ 402.781 480.728 144.872 72.386 3.069.620 Share 37,8% 32,2% 33,4% 40,1% 28,2% 3 Less developed regions comprise all regions of Africa, Asia (except Japan), Latin America and the Caribbean plus Melanesia, Micronesia and Polynesia. POPULATION AND DEMOGRAPHICS 31ABRAMED PANEL

In Brazil, the demographic dynamics has The pace of ageing occurred slowly in the intensified and accelerated the population second half of the 20th century and more aging process, resulting in a high quantity and rapidly in the first half of the 21st century. This ratio of the elderly population, in comparison trajectory is expected to be maintained until with other age groups. In 2021, the country the second half of the 21st century, and then has the 6th largest elderly population in the gradually decline. world, around 31.3 million, which translates into 14.5% of the population. GRAPH PROJECTION OF THE TOTAL POPULATION, ELDERLY (60+) AND SHARE OF THE ELDERLY POPULATION (IN % – BRAZIL – 1950/2100) 5 Source: United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Online Edition. Rev.1. Prepared by Abramed. 250.000 45% 200.000 40% 150.000 35% 100.000 30% 50.000 25% -- 20% 15% 10% 5% 0% 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2055 2060 2065 2070 2075 2080 2085 2090 2095 2100 60+ Total Share Chronic non-communicable diseases population, especially the elderly. More than (NCDs) represent the problem of greatest half the population aged 18 years or older in magnitude in health and account for the the country report diagnosis of at least one high number of premature deaths, with chronic disease. repercussions on the quality of life of the 32 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

GRAPH SHARE OF PEOPLE AGED 18 YEARS OR OLDER WHO REPORT A DIAGNOSIS OF SOME CHRONIC PHYSICAL OR MENTAL ILLNESS (IN % – BRAZIL – 2019) 6 Source: IBGE, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento, Pesquisa Nacional de Saúde 2019. Prepared by Abramed. High Blood Pressure 23,9 Chronic Back Problem 21,6 Depression Diabetes 10,2 Arthritis or Rheumatism 7,7 Other Mental Disease 7,6 Heart Disease 6,5 Asthma 5,3 Cancer 5,3 WSMDs 2,6 Stroke 2,5 Lung Disease 2 Chronic renal failure 1,7 1,5 Population ageing is associated with widespread The incidence of chronic diseases increases with improvement in health conditions and the age and affects mainly the elderly. Therefore, development of medicine. In this sense, the the consequences of demographic dynamics importance of diagnostic tests in the healthcare cause a growing demand for health services. It is cycle stands out. In several situations, tests estimated that the demand for diagnostic tests can identify a health condition before the should grow 96% by 2050, due to population manifestation of symptoms, reducing treatment aging and variations in the income level of the costs and providing well-being to the patient. population. POPULATION AND DEMOGRAPHICS 33ABRAMED PANEL

Tests needed for quick and accurate diagnosis - chronic non-communicable diseases (NCDs) According to the World Health Organization per year, which represents approximately (WHO), NCDs can be defined as long-lasting 71% of all causes of death worldwide. Early and silent diseases until the manifestation of detection by means of diagnostic tests is one the first symptoms. They result from various of the instruments capable of assisting in the reasons, especially risk factors such as smoking, management and guidance of health policies. insufficient physical activity, malnutrition, In Brazil, more than half (52%) of the people obesity and excessive alcohol consumption. aged 18 years or more report a diagnosis of at The combination of these factors leads to least one chronic disease4. the mortality of about 41 million people Hipertension The pandemic affected outpatient care during the period of social isolation. As a consequence, Cardiovascular diseases are responsible for the number of examinations performed for most deaths associated with NCDs, among disease monitoring decreased by about 54.5% which, arterial hypertension stands out. Better between 2020 and 2019. known as high blood pressure, it affects around 23.9% of the Brazilian population over 18 years Cardiovascular of age, and up to 62.1% of people aged 75 years diseases are or more. Hypertension may reduce patients’ responsible for the life expectancy by up to 40% if not properly majority of deaths controlled5. Diagnosis is based essentially on associated with two blood pressure measurements: in a resting NCDs. situation and another under environmental conditions, since psychological factors, such as stress, can influence blood pressure. ABPM (Ambulatory Blood Pressure Monitoring) is the test indicated to help monitor blood pressure and can prevent serious diseases, especially in older age groups, which are usually affected by cardiovascular diseases. 4 National Health Survey 2019. 5 World Health Organization (WHO). 34 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

GRAPH NUMBER OF AMBULATORY BLOOD PRESSURE MONITORING EXAMINATIONS (MAP) BY AGE BRACKET IN BRAZIL (SUS – 2016/2021) 7 Source: Ministério da Saúde - Sistema de Informações Ambulatoriais do SUS (SIA/SUS). Extracted on Septem- ber 1st, 2021. Prepared by Abramed. Note: The quantity by age bracket was calculated considering the proportion observed according to age bracket and the total classified as Not informed/not required and Total. NUMBER OF TESTS 200.000 180.000 160.000 140.000 120.000 100.000 80.000 60.000 40.000 20.000 0 <1 1 - 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+ 2016 2017 2018 2019 2020 2021 (ATÉ JUN) The reduction in the number of exams may cause a faster increase in costs associated with the treatment of the disease, and preventive measures should be intensified. It is a low-cost exam, with an estimated average value of R$ 109.19, according to data from the National Agency of Supplementary Health (ANS), in 2019. Prevention and early detection of diseases, as well as health promotion, are fundamental to ensure the sustainability of health systems, public or private. In SUS, the estimated costs attributable to hypertension for hospitalizations, outpatient procedures and medications in adults, totaled about R$ 2 billion, in the year 20186. 6 Costs attributable to obesity, hypertension, and diabetes in the Brazilian National Health System, 2018. POPULATION AND DEMOGRAPHICS 35ABRAMED PANEL

Reducing the number of examinations could lead to a more rapid increase in the costs associated with the treatment of various diseases. GRAPH NUMBER OF AMBULATORY BLOOD PRESSURE MONITORING EXAMINATIONS (MAP) WITH DIABETES (SUS AND SUPPLEMENTARY HEALTH - 2015/2019) IN MILLION 8 Source: Ministério da Saúde - Sistema de Informações Ambulatoriais do SUS (SIA/SUS) and Painel dos Dados do TISS - ANS Extracted on September 1st,2021. Prepared by Abramed. 1,7 1,7 1,2 1,4 1,2 1,3 0,9 1,1 1,1 0,6 2015 2016 2017 2018 2019 Supplementary healthcare SUS 36 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

POPULATION AND DEMOGRAPHICS 37ABRAMED PANEL

Diabetes mellitus 16.8 million Brazilians with diabetes in 2019. The attributable costs for hospitalizations, Scientifically known as Diabetes mellitus, it outpatient procedures and medications in is the most common disorder involving the adults in SUS was R$1.1 billion in 2018.7 metabolism of sugars and is characterized by increased glucose levels in the blood (hyperglycemia). It is an increasingly prevalent condition in Brazil and worldwide. According to the International Diabetes Federation (IDF), there are approximately 463 million diabetics aged between 20 and 79 years worldwide, mainly in low and middle-income countries. By 2045, there are an estimated 700 million people with diabetes. Spending on the disease represents about 10% of total adult medical expenditure and was equivalent to US$760 billion in 2019. In Brazil, the IDF estimated TABLE TOP 10 COUNTRIES WITH ADULT POPULATION (20-79 ANOS) WITH DIABETES (2019, 2030 AND 2045) – IN MILLIONS 5 Fonte: IDF DIABETES ATLAS Ninth edition 2019 Rev. 1. Adapted by Abramed. 2019 NUMBER 2030 NUMBER 2045 NUMBER OF PEOPLE OF PEOPLE OF PEOPLE RANK COUNTRY WITH RANK COUNTRY WITH RANK COUNTRY WITH DIABETES DIABETES DIABETES 1st China 1st China 1st China 2nd India 116,4 2nd India 140,5 2nd India 147,2 3rd United States 77 3rd United States 101 3rd Pakistan 134,2 4th Pakistan 31 4th Pakistan 34,3 4th United States 37,1 5th Brazil 19,4 5th Brazil 26,2 5th Brazil 36 6th Mexico 16,8 6th Mexico 21,5 6th Mexico 26 7th Indonesia 12,8 7th Indonesia 17,2 7th Egipt 22,3 8th Germany 10,7 8th Egipt 13,7 8th Indonesia 16,9 9th Egipt 9,5 9th Bangladesh 11,9 9th Bangladesh 16,6 10th Bangladesh 8,9 10th Germany 11,4 10th Turkey 15 8,4 10,1 10,4 7 Costs attributable to obesity, hypertension, and diabetes in the Brazilian Unified Health System (SUS), 2018. 38 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

Diabetes is a serious disease which, if poorly called glycaemia (random or fasting) is the test controlled, can cause various vascular used to screen for diabetes. Other routine tests problems in the eyes, nerves, kidneys, and that may be performed to monitor patients heart. These consequences, however, can be include blood glucose, hemoglobin, urea, reduced with systematic control of the disease, creatinine, microalbumin and lipid profile. done mainly by keeping blood glucose rates Other tests may be recommended according to within certain limits, as well as screening for the individual needs of the patient. chronic complications, always under medical supervision. Early diagnosis of diabetes is important not only for prevention of acute complications caused by the disease, but also for prevention of chronic complications. The blood glucose test GRAPH NUMBER OF GLYCATED HAEMOGLOBIN TESTS, BY AGE BRACKET IN BRAZIL (SUS – 2016/2021) 9 Source: Ministério da Saúde - Sistema de Informações Ambulatoriais do SUS (SIA/SUS) and Painel dos Dados do TISS - ANS Extracted on September 1st 2021. Prepared by Abramed. Note: SUS amount was estimated for 2015. NUMBER OF TESTS 140.000 120.000 100.000 80.000 60.000 40.000 20.000 0 < 1 1 - 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+ 2016 2017 2018 2019 2020 2021 (UP TO JUN) POPULATION AND DEMOGRAPHICS 39ABRAMED PANEL

The test of glycated hemoglobin (A1 total) research and/or dosage, presented an average value of R$ 13.67 between 2015 and 2019, according to data from ANS. Detection actions with guaranteed access to diagnostic tests, in adequate time and with quality at all stages of the disease’s care line are cost-effective measures, contributing to the optimization of scarce resources of health systems. GRAPH NUMBER OF GLYCATED HEMOGLOBIN TESTS IN BRAZIL (SUS AND SUPPLEMENTARY HEALTH – 2015/2019) – IN MILLIONS 10 Source: Ministério da Saúde - Sistema de Informações Ambulatoriais do SUS (SIA/SUS) and Painel dos Dados do TISS - ANS. Extracted on September 1st, 2021. Prepared by Abramed. 3,2 6,3 1,7 5,8 5,3 4,4 1,6 1,6 1,6 1,7 2015 2016 2017 2018 2019 Supplementary health SUS 40 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

01.2.2 Fertility and birth rates The covid-19 pandemic influenced reproductive of an increase in fertility in the coming decades, behavior considering the unfavorable as shown by IBGE and UN Population Division conjuncture and the uncertainty in the face of projections. Despite the reduction in the fertility economic, social and political restrictions. In rate, the number of births increased until 1985. this sense, it is estimated a more accelerated There were more women in reproductive age, reduction in the number of births and children but they were having fewer children. Since per woman. then, the number of births has been in decline, and projections indicate that this trend will The fertility and birth rate in Brazil has shown a remain until the end of the century, with some systematic reduction since 1960. This reduction is negative variations caused by the unfolding of expectedtocontinueandtherearenopredictions the pandemic on Brazilians’ family planning. GRAPH BIRTHS PER YEAR AND FERTILITY RATE IN BRAZIL (IN % PER FIVE-YEAR PERIOD – 1950-2100) 11 Source: United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Online Edition. Rev. 1. Prepared by Abramed. 6,1 6,1 6 5,3 4,6 4,2 3,8 3,1 2,7 2,5 2,1 1,9 1,8 1,7 1,7 1,6 1,6 1,6 1,6 1,6 1,6 1,6 1,6 1,6 1,6 1,7 1,7 1,7 1,7 1,7 1950-55 2.556 1955-60 2.878 1960-65 3.217 1965-70 3.320 1970-75 3.338 1975-80 3.695 1980-85 3.949 1985-90 3.780 1990-95 3.643 1995-2000 3.618 2000-05 3.370 2005-10 3.066 2010-15 2.975 2015-20 2.934 2020-25 2.763 2025-30 2.585 2030-35 2.445 2035-40 2.318 2040-45 2.218 2045-50 2.143 2050-55 2.066 2055-60 1.984 2060-65 1.906 2065-70 1.832 2070-75 1.771 2075-80 1.716 2080-85 1.667 2085-90 1.616 2090-95 1.568 2095-2100 1.520 Average Annual Births (thousand) Fertility Rate POPULATION AND DEMOGRAPHICS 41ABRAMED PANEL

01.2.3 Life Expectancy at Birth (LER) IN BRAZIL, THERE IS NO RECORD OF A REGRESSION IN THE GAINS IN LIFE EXPECTANCY IN THE LAST CENTURY, UNTIL THE ONSET OF THE COVID-19 PANDEMIC. The health crisis caused by the pandemic development of socioeconomic conditions, has considerably reduced the life expectancy health and education, among others. It is a of Brazilians. Life expectancy at birth is a structural indicator that oscillates positively demographic measure influenced by the with life gains and rarely regresses. 42 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

TABLE DISTRIBUTION OF THE RESIDENT POPULATION AND MUNICIPALITIES BY POPULATION BRACKET (QUANTITY AND PERCENTAGE DISTRIBUTION - BRAZIL - 2021) 6 Source: IBGE. Diretoria de Pesquisas - DPE - Coordenação de População e Indicadores Sociais - COPIS. Prepared by Abramed. Note: Estimates of the population living in Brazilian municipalities with reference date on July 1st, 2021. Year Total Men Women Diferencial between sexes 1940 45,5 42,9 48,3 5,4 1950 48 45,3 50,8 5,5 1960 52,5 49,7 55,5 5,8 1970 57,6 54,6 60,8 6,2 1980 62,5 59,6 65,7 6,1 1990 66,9 63,2 70,9 7,7 2000 69,8 66 73,9 7,9 2010 73,9 70,2 77,6 7,4 76,3 72,8 79,9 7,1 2018 76,5 73 80 7 2019 76,7 73,3 80,3 7 75,2 71,4 79,1 7,6 2020 PROJECTED 2020 77 73,5 80,5 7 COVID-19 ESTIMATE 73,4 69,6 77,4 7,9 2021 PROJECTED 2021 31,5 30,6 32,2 1,6 COVID-19 ESTIMATE 27,9 26,7 29,1 2,5 (1940/2021) (1940/2021) COVID-19 IMPACT This reduction interrupts a growth path in life expectancy as of 1940, with an average of 45.5 years, until it reaches 77 years, projected for 2021, a gain of 31.5 years in the period. However, the decrease in the population due to mortality associated with the developments of covid-19 indicates a reduction of 3.6 years in the life expectancy of the population between 1940 e 2021. POPULATION AND DEMOGRAPHICS 43ABRAMED PANEL

01.2.4 Mortality and morbidity The pandemic found a pattern of morbidity accidents. However, covid-19 provoked a and mortality in the country in which “temporary epidemiological transition”, with the main causes of death were associated a significant increase in the number of deaths with chronic noncommunicable diseases caused by infectious diseases, especially (NCDs) and external causes of morbidity related to the new coronavirus. and mortality, such as violence and traffic TABLE DEATHS BY PLACE OF HOSPITALIZATION - ICD-108 CHAPTER (BRAZIL – 2019/2021) 7 Source: Ministério da Saúde - Sistema de Informações Hospitalares do SUS (SIH/SUS). SUS Hospital Morbidity - by place of hospitalization - Brazil - Deaths by year/month processing according to ICD-10 Chapter. Extracted on August 1st, 2021. Prepared by Abramed Note: Except VII. Diseases of the eye and annexes, VIII. Diseases of the ear and mastoid apophysis and XX. External causes of morbidity and mortality. RANK CHAPTER - CID 10 2019 2020 2021 % JAN/MAY % JAN/MAY % JAN/MAY 2021 JAN-MAY JAN-MAY JAN-MAY 2020/2019 2021/2020 2021/2019 1st I. Some infectious and parasitic diseases 39.780 48.835 176.581 22,8% 261,6% 343,9% 2nd IX. Circulatory System Diseases 38.781 38.358 38.213 -1,1% -0,4% -1,5% 3rd X. Respiratory system diseases 37.836 39.988 36.347 5,7% 9,1% -3,9% 4th II. Neoplasias (tumours) 29.894 29.413 27.859 -1,6% -5,3% -6,8% 5th XI. Digestive Tract Diseases 15.705 15.337 15.420 -2,3% 0,5% -1,8% 6th XIX. Injuries, poisoning and some other 11.409 11.273 11.958 -1,2% 6,1% 4,8% consequences or external causes 10.840 10.291 9.756 -5,1% -5,2% -10,0% 7th XIV. Genitourinary system diseases 6.886 6.554 6.996 -4,8% 6,7% 1,6% 8th XVIII. Symptoms, signs and abnormal findings 5.627 5.110 4.791 -9,2% -6,2% -14,9% on clinical and laboratory examinations 9th IV. Nutritional Endocrine and Metabolic 5.070 4.712 4.589 -7,1% -2,6% -9,5% Diseases 3.636 3.623 3.492 -0,4% -3,6% -4,0% 10th XVI. Some diseases originated in the 2.109 2.023 2.014 -4,1% -0,4% -4,5% perinatal period 1.687 1.690 1.588 0,2% -6,0% -5,9% 11th VI. Nervous system diseases 12th III. Diseases of the blood, blood organs 867 915 843 5,5% -7,9% -2,8% and immune disorders. 483 568 633 17,6% 11,4% 31,1% 13th XII. Skin and subcutaneous tissue 567 502 510 -11,5% 1,6% -10,1% diseases 393 360 493 -8,4% 36,9% 25,4% 14th XVII. Congenital malformation and 489 497 446 1,6% -10,3% -8,8% chromosomal abnormalities 15th XXI. Contacts with health services 16th XIII. Diseases of the musculoskeletal system and connective tissue 17th XV. Pregnancy, childbirth and puerperium 18th V. Mental and Behavioral Disorders Total 212.089 220.065 342.546 3,8% 55,7% 61,5% 44 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

The set of NCDs accounted for about 62.5% of deaths in 20209, followed by external causes of morbidity and mortality, which accounted for 11.7% of total deaths. NCDs are the leading cause of mortality and premature disability in most countries of our continent, including Brazil. In the last ten years there was an average increase of 31.4% in the number of these deaths, according to data from the Ministry of Health. TABLE DEATHS BY PLACE OF RESIDENCE - ICD-10 (BRAZIL – 2010/2020) 8 Source: MS/SVS/CGIAE - Sistema de Informações sobre Mortalidade – SIM. Deaths by place of residence according to ICD-10 chapter. Extracted on August 1st, 2021. Prepared by Abramed. Note: The year 2020 considers the total number of deaths according to the Transparency Portal and the distribution according to the ICD-10 chapter the average proportion of deaths over the last 3 years according to data from the Ministry of Health. RANK CAPÍTULO - CID 10 2010 2020 % NUMBER 2021 2010/2020 OF DEATHS 326.371 397.273 2010/2020 1s1tº IX. DCiorceunlçaatosrdyoSyasptaermelhDoisceiracsuelsatório 178.990 251.759 21,7% 2nd II. Neoplasias(tumors) 119.114 173.771 40,7% 70.902 13ºrd XIX..RDeosepnirçaatosrdyosyasptaermelhdoisceiarcsueslatório 143.256 166.342 45,9% 72.769 4th XX. External causes of morbidity and mortality 70.276 89.866 16,1% 54.657 51ºth IXV. NDuoternitçioansadl oEnadpoacrerilnheoacnirdcuMlaettóarbioolic Diseases 79.622 79.858 27,9% 23,086 6th XVIII. Symptoms, signs, and abnormal findings clinical and 0,3% 19.590 58.061 236 laboratory examinations 48.823 74.294 28,0% 71ºth XIXI. Diogeensçtiaves dTroacatpDariseelhaosecsirculatório 24.519 61.092 25,1% 16.233 8th XVI. Some infectious and parasitic diseases 25.303 48.290 96,9% 12.269 19ºth IXXIV. D. Goeniçtoasurdinoaarypsayresltheomcdircisuelaastóersio 23.723 45.937 81,5% 23.771 10th VI. Nervous system diseases 12.759 23.099 -3,0% 20.634 1º1th IXXV. ID. Sooemnçeasdidsoeaaspeasreolrhigoincairtceudlaintótrhioe perinatal period 10.196 15.093 18,3% 714 12th V. Mental and Behavioural Disorders 12.298 20,6% 2.334 1º3th IXXV. IDI. oCeonnçgaesnditoalamparlfeolhrmo actiriocnulatnódriochromosomal 6.284 2.102 7.456 18,7% abnormalities 3.225 1.172 14th III. Diseases of the blood, blood organs and immune 4.541 7.171 122,4% 6.824 50,3% 3.946 disorders. 1.728 2.283 1º5th XIXI.I.DSokeinnçaansddsoubacpuatraenlheooucsirctiuslsautóerdioiseases 125 2.009 16,3% 16th XIII. Diseases of the musculoskeletal system and connective 31 281 1.136.947 203 62,8% 78 tissue -8 17º th XIXV..DPoregnnçaanscdyo, cahpiladrbeilrhtho, cainrcduplautóerpioerium 23 -25,4% 325.621 18th VIII. Ear and mastoid apophysis diseases 1º9th VIXI.I.DEoyenaçnads addonaepxarledlhisoeacsirecsulatório 1.462.568 28,6% Total 8 CD-10 - The International Classification of Diseases and Related Health Problems (also known as the International Classification of Diseases - ICD-10) is published by the World Health Organization (WHO) and aims to standardize the coding of diseases and other health-related problems. ICD-10 provi- des codes relating to the classification of diseases and a wide variety of signs, symptoms, abnormal aspects, complaints, social circumstances and external causes for injury or illness. Each health condition is assigned a unique category with a corresponding ICD-10 code. 9 The number of deaths in 2020 considers the total number of deaths according to the Transparency Portal and the distribution according to the ICD-10 chapter, considering the average in the last three years according to data from the Ministry of Health. POPULATION AND DEMOGRAPHICS 45ABRAMED PANEL

GRAPH DEATHS BY PLACE OF RESIDENCE - ICD-10 CHAPTER (BRAZIL - 2020) 12 Source: MS/SVS/CGIAE - Sistema de Informações sobre Mortalidade - SIM. Extracted on August 1st, 21. Prepared by Abramed. IX. II. Neoplasias II. XX. Circulatory (tumors) Respiratory External System Diseases system causes of 251.759 diseases morbidity 397.273 and 173.771 mortality 166.342 IV. Nutritional, Endocrine, and Metabolic Diseases 89.866 46 ABRAMED PANEL POPULATION AND DEMOGRAPHICS

The proportion of deaths in relation to the population aged 60 years or older over the total indicates a significant increase in occurrences associated with NCDs between 1997 and 2019. With advancing age, the number of people with chronic diseases increases. Most of these diseases are caused by risk behaviors such as smoking, high alcohol consumption, obesity, high cholesterol, sedentary lifestyle, among others. Generally, the development of chronic diseases associated to risk factors is silent and does not present any symptoms in its early stages. The performance of preventive diagnostic exams is essential to identify the first signs of several diseases. GRAPH PROPORTION OF DEATHS BY ICD-10 CHAPTER IN PEOPLE AGED 60 YEARS OR MORE (IN % – BRAZIL – 1997 AND 2019 – DCNT) 13 Source: MS/SVS/CGIAE - Sistema de Informações sobre Mortalidade - SIM. Extracted on August 1, 21. Prepared by Abramed. 100 95 84,8 90 80,6 85 80,0 74,1 80 75 73,1 70 68,1 68,0 65 60 61,8 55 50 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 II. Neoplasias (tumors) IV. Nutritional, Endocrine, and Metabolic Diseases IX. Circulatory System Diseases X. Respiratory system diseases POPULATION AND DEMOGRAPHICS 47ABRAMED PANEL

48 ABRAMED PANEL

Economic Environment 02 49ABRAMED PANEL

02 ECONOMIC ENVIRONMENT THE START OF VACCINATION AGAINST COVID-19 BROUGHT POSITIVE EXPECTATIONS FOR THE ECONOMY’S PERFORMANCE, DESPITE THE UNCERTAINTIES REGARDING THE EMERGENCE OF NEW STRAINS IN THE COUNTRY AND THE GROWING NUMBER OF DEATHS IN THE FIRST HALF OF THE YEAR. EVEN WITH ACCESS TO VACCINATION, ALBEIT PRECARIOUSLY, THE COUNTRY WILL FACE THE EFFECTS OF THE PANDEMIC ON THE LEVEL OF ECONOMIC ACTIVITY FOR A LONG PERIOD OF TIME. 50 ABRAMED PANEL ECONOMIC ENVIRONMENT