Trade and Investment

To bring universal healthcare to Africa, the private sector must get involved

Public budgets are below $30/capita per year in 11 sub-Saharan African countries. Image: Hush Naidoo/Unsplash

Pascal Fröhlicher
Executive director, U-Care
Carlijn Nouwen
Partner, Dalberg Advisors
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No one doubts the impact of achieving universal health coverage (UHC) for both individuals and society at large. Many countries in sub-Saharan Africa (SSA) are currently striving for exactly the greater access to care, dignified standard of treatment and improved health outcomes that UHC could bring. But existing limited budgets from both governments and international donors paired with challenges in implementation capacity mean this cannot be achieved without the private sector.

Though there's no magic number, public budgets below $30 per capita per year in 11 SSA countries and $30-60 per capita per year in another 13 countries are far from sufficient. In most of these countries, private-sector activity already plays a substantial role in healthcare delivery, as the graph below shows (in which out-of-pocket (OOP) healthcare expenditure is used as an – admittedly imperfect – proxy for private sector activity).

Healthcare expenditure for countries in SSA, split into out-of-pocket and other finance sources (ranked by % of OOP) Image: WHO Global Health Expenditure database, 2016 data

The private sector is indispensable to achieving UHC of decent coverage and quality, but its potential is often not fully exploited. Most commonly, it is on the one hand targeted as (co-) funder, either for philanthropic cash contributions or in-kind with goods and services at a subsidized rate. On the other hand, recognizing the sector’s ability to deliver efficiently and transparently, many governments contract private-sector actors to build and operate health facilities on their behalf (e.g., in a PPP structure).

Reaching UHC2030 through conventional means remains, however, ambitious at best. The gap is too big to close through traditional private-sector contributions or efficiency gains. Fundamental rethinking of healthcare is required through private sector-led innovation.

Traditionally, private provision at the primary healthcare level has been a fragmented set of largely individual providers, varying hugely in quality and providing little connection into a structured healthcare system. Yet recently, business model innovations have given rise to larger and better providers that can be instrumental in achieving UHC across the African continent.

Key levers of innovation include the use of standardization, task-shifting and remote care provision – which are often combined to get a wide reach at high quality and affordable cost. Standardization ensures the best known course of action (“evidence-based care”) is taken for every patient, without allowing for (much) deviation based on the opinion of the healthcare professional that treats the patient. Often, AI-enabled decision tools can provide standard knowledge to the professional, leaving him/ her certain discretion for deviations based on the individual case. Task-shifting optimizes the use of scarce human resources, by making sure no healthcare professional performs tasks that a less-qualified person could also do. For example: a doctor doesn’t need to take a patient’s vitals. Standardization enables providers to take task-shifting a step further.

This is by no means theoretical – many real-life examples exist:

Babyl offers a system of medical triage and clinical consultations in Rwanda using a USSD platform on feature phones, a call centre for remote consultations, and an SMS-based system for issuing digital prescriptions that can be filled at any of around 200 partner pharmacies in Rwanda. In close collaboration with the Rwandan government, Babyl is preparing for the next phase of innovation that will be strongly anchored in AI.

U-Care, a South African low-cost primary and occupational care provider, uses task-shifting along with standardization of care with a focus on efficient management, evidence-based care and an operational drive for high utilization. U-Care makes extensive use of clinical associates in first patient contact, with a medical doctor being available for referral and to ensure quality assurance.

Jacaranda Health combines business and clinical innovations to create a fully self-sustaining and scalable chain of maternity clinics in Kenya. Nurses provide all clinical care, while patient care assistants (nurse aides) provide non-clinical care, and community health workers (CHWs) manage home visits and client education. Nurses are also positioned to be healthcare systems leaders and managers. Jacaranda is also working on AI-enabled clinical decision support systems to improve efficiency. Mobile phone-based systems capture and track client data and health trends, and send patients customized health tips and scheduling reminders.

Healthforce is a nurse-centric model in South Africa, combining aspects of face-to-face care and remote care provision to support task-shifting. Healthforce’s digital clinic management system empowers nurses to initiate telemedicine consultations between remote doctors and their local patients. Nurses, fulfilling the carer role, perform physical examinations and take vital signs and medical history. They can then connect to doctors immediately, without needing to book. Once connected, the three-way consultations between nurse, patient and doctor are led by the nurses – with the latter as the triage gatekeeper, patients only need pay a nominal fee if the nurse can provide the required care, and a vastly reduced doctor consult fee if one needs to be called into the consultation.

These efforts in innovation can be fostered by private sector or civil society, but need at least the buy-in of governments as enablers, partners, or even purchasers of the product or solution on offer. Getting these models to work, at scale and in a financially sustainable manner, is far from easy. Typical barriers to overcome include:

  • Issues around the regulatory environment and protectionist industry associations – in most countries, the legal definition of a “medical consultation” is defined as a doctor physically engaging with a patient and anything different is not permissible. This requires regulatory innovation to enable task-shifting and remote care.
  • A lack of appropriate capacity and government procedures for working with non-state actors – be it in procurement, management or joint drive towards innovation. This includes long lead times for development and high upfront investments needed to develop innovative solutions that are at odds with public procurement processes. The long waiting time for public procurement decisions can put emerging companies in jeopardy. Similarly, early-stage innovation whose business model depends on high volumes will need a significant period to reach break-even that might be at odds with shorter public contracts.
  • Shortcomings in the education of clinical personnel with regards to innovation and business skills and limited availability of the right calibre of talent in the country of operation.
  • Challenges to secure the right type of capital as the innovative business grows and its capital needs evolve. Many innovations struggle to sustain themselves in the transition period from start-up funding to risk capital or other funding sources.
  • Lack of collaboration within the private health sector, as some incumbent solutions disrupt existing and profitable (but not inclusive) business models

Low-cost, for-profit private provision is a critical element to support governments and donors to achieve UHC in a sustainable way. However, support is needed to develop, test and scale these innovations. This prerogative is often given to philanthropic institutions. If UHC2030 is to become a reality, we have to go beyond product innovation and also need to innovate in terms of the way different actors in the health system collaborate.

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