SINGAPORE (Nikkei Markets) -- Singapore's healthcare players are shifting strategy as rising costs and growing competition erode the city-state's appeal as a destination for medical tourism.

Companies like IHH Healthcare Bhd and Raffles Medical Group are expanding overseas at a robust pace, leveraging on the brand names they've already established to draw increasingly affluent patients in populous countries such as China and India.

Whether they'll succeed is open to debate. The upfront costs of opening a hospital are huge and margins are already under pressure, say industry watchers. However, the companies lack other options for growth.

Although the rapidly aging Singapore population and the shortage of beds at government-run facilities could help demand, the increasing reliance on lower-margin domestic patients poses a risk to the profits of private hospitals.

IHH, Asia's largest healthcare firm which is listed in Kuala Lumpur and Singapore, operates the well-known Mount Elizabeth and Gleneagles hospitals in the city-state. In March, it opened the 500-bed Gleneagles Hong Kong and is in the process of setting up hospitals in the Chinese cities of Chengdu, Nanjing and Shanghai that will open in the next four years.

IHH already operates hospitals in Malaysia, India and Turkey.

In an interview with the Financial Times published this week, Tan See Leng, IHH's chief executive, said that he is looking at a "bunch of assets" in India as the healthcare giant expands beyond its foothold in the southern part of the country. Reports in other media have pointed to Fortis Group, one of India's largest healthcare chains, as a likely target.

Meanwhile, smaller rival Raffles Medical is in the process of building hospitals in Shanghai and Chongqing that are slated for completion sometime next year.

According to IHH's 2016 annual report, the average revenue per admitted patient in Singapore stood at 27,543 ringgit ($6,418) in FY2015/16, down slightly from 27,660 ringgit in the previous financial year. The cost incurred by the average patient in Singapore was more than four times the 5,915 ringgit paid by the average patient at its Malaysian hospital, although that was partly due to the more complex cases treated in Singapore.

Singapore has long been regarded as a premier healthcare destination in Asia thanks to its highly trained doctors and well-equipped private and government-run hospitals. However, costs are high in comparison to neighboring ASEAN countries such as Malaysia and Thailand, where the quality of care has improved so much over the past decade that more and more Singapore residents are seeking medical treatment there.

Bumrungrad International, Thailand's top hospital, said its international patients include Singaporean nationals and residents, who visit Bangkok for health screening and preventative medicine as well as to consult specialists in areas such as obstetrics and gynecology.

"We are also 25-35% cheaper than Singaporean private hospitals, and have been benchmarked by third parties to have similar or higher quality levels as the top hospitals there," said Sudi Narasimhan, the hospital's corporate director of marketing and business development.

Bumrungrad is about 24% owned by Bangkok Dusit Medical Services PCL, Thailand's biggest healthcare group, although it operates independently from its major shareholder.

Singapore has not provided medical tourism figures in recent years but data from Malaysia Health Travel Council show 921,000 visitors sought treatment in the country last year, up more than 40% from 643,000 in 2011. Bumrungrad said it sees around 520,000 international patients from over 190 countries each year.

Besides IHH and Raffles Medical, the other Singapore healthcare players include unlisted Thomson Medical, Health Management International Ltd, whose operations include two hospitals in Malaysia, and specialist medical clinics such as TalkMed and Singapore O&G.

In a report last week, UOB Kay Hian said that medical tourism growth in Singapore looked set to slow further despite the global boom in demand for quality healthcare, with private hospitals having to rely more on lower-margin local patients.

While Singapore still remains a compelling medical tourist destination in terms of service quality and clinical outcomes, foreign patient growth may slow gradually due to competition from neighboring ASEAN countries, the brokerage said.

UOB Kay Hian also said the average bill size per patient in Singapore is now growing at an average of 1-2% a year, down from 5% as recently as in the financial year ended March 2014, based on data provided by IHH.

Despite Singapore's loss of competitiveness in the market for international patients, analysts believe private hospitals at home could benefit from a spillover from public hospitals. According to UOB Kay Hian, bed occupancy levels at government-owned hospitals remain between 82-97%, exceeding the standard of 82-85% set by the Australian Medical Association and the Australasian College of Emergency Medicine.

Maybank Kim Eng said that while growth in Singapore has slowed due to a decrease in medical tourism, "the structural growth drivers remain positive driven by an aging population, rising affluence, increasing prevalence of chronic diseases and demand for quality services."

Looking ahead, analysts are more positive in their outlook for IHH as compared with Raffles Medical, although some warn that valuations are high at 53 times forecast earnings compared to the average price-earnings ratio of around 40 for healthcare groups in Asia.

The high valuation is due to IHH's larger geographical footprint and exposure to faster growing markets such as Malaysia and India.

However, there is caution about Raffles Medical's near-term prospects due to margin pressures in Singapore, its main source of revenue, as well as upfront costs associated with its expansion into China.

"Margins are now at a low but could go even lower...Margin pressure will only further intensify due to start-up costs for its Singapore hospital extension opening in 4Q17 and start-up costs for its 700-bed hospital in Chongqing due to open in mid-18," CIMB Research said in a recent report.

--Kevin Lim