The Cure

Africa’s healthcare systems may be transitioning out of decades of internationally funded ‘crisis mode’, and moving towards more sustainable models of public and private care provision.

When Agnes Binagwaho returned to her native Rwanda in 1996, the country’s health system was in tatters. Thousands had died in the genocide, and many professionals had fled. The physical infrastructure — the hospitals and clinics — were overwhelmed, the human capital had disappeared and the structures of governance and government on which the system had been built had been destroyed.

“In the entire country, we had less than 15 paediatricians, and that was one of the better specialities,” she says. “It was a dramatic situation. Life expectancy was far less than 40 years.”

Two decades on, Rwanda is the only country in sub-Saharan Africa that is likely to come close to completing the full sweep of the Millennium Development Goals on health. Between 2004 and 2014, the maternal mortality rate fell by 60%, while deaths from malaria, tuberculosis and HIV/Aids fell by 80% each. Between 1994 and 2012, life expectancy doubled.

Binagwaho is now Rwanda’s minister of health, as well as a senior lecturer at Harvard Medical School and a professor of paediatrics at the Geisel School of Medicine in the US. She believes that the evolution of the country’s healthcare system has been central to its economic success — gross domestic product per capita grew from $667 in 2000 to $1,800 in 2015.

Rwanda is an outlier in sub-Saharan Africa; one of the few that has built a healthcare system that reaches out of urban centres and into rural communities, blending public and private sector services through its public health insurance scheme, the Mutuelles de Santé, which covers 90% of the population. Private, military and other public service health plans cover a further 7% of Rwandans.

6,000km away, in West Africa, an outbreak of the Ebola virus in three other small, post-conflict countries has highlighted the economic causes and consequences of growth without investment in sustainable healthcare systems.

As the outbreak subsides, African governments and the international community are re-examining how they can turn around the legacy of decades of aid and public sector investment to build systems that work for the long-term, while the private sector is stepping up into the gaps in service provision.

Counter-intuitively, experts say, the Ebola crisis could be the catalyst to end the persistent ‘state of emergency’ in African healthcare.

“I think in a way the Ebola epidemic has been a blessing in disguise,” says Catherine Kyobutungi, director of research at the African Population Health Research Centre in Nairobi and an expert in health systems.

“It showed the quicksand on which the systems have been standing, despite the massive investments for years and years… Perhaps this is what we’ve been waiting for a long time; where finally we realised that without the fundamentals being in place, all of these systems are just standing on shaking ground.”

Global priorities

Government expenditures on health in the World Health Organisation’s Africa Region averaged 9.7% of their total budgets in 2011, the last year for which figures are available, compared with a global average of 15.2%. Total expenditure on health was on average 6.2% of GDP in Africa, against a global aggregate of 9.1%.

African countries are disproportionately dependent on external resources for healthcare financing, WHO figures show. Out of the continent’s total healthcare budget, almost 12% comes from international sources, versus a global average of just 0.4%.

International funding for health in Africa has, for more than a decade, focused on narrowly targeting a small number of diseases — in particular HIV/Aids, tuberculosis and malaria — on vaccinations and on emergency response.

“At the height of the AIDS epidemic, there was this consensus that something needed to be done, but … since then, we’ve never moved out of the emergency situation,” Kyobutungi says. “But there’s been no serious engagement in long-term capacity.”

Estimates vary, but most analyses suggest that only 25% of the total international aid funding flowing into healthcare has gone to supporting primary health systems.

Some critics believe that the increasing influence of giant philanthropic organisations working in the health sector has exacerbated this imbalance, with institutions, such as the Bill & Melinda Gates Foundation, focusing on disease eradication, rather than holistically building the capacity of the healthcare sector.

“They may deny it, but governments’ choices are driven by international sources, because governments work on strategic plans. The components of the strategic plans that get implemented are the ones that get funded,” Kyobutungi says.

Not everyone accepts that the intense focus on specific communicable diseases has been corrosive to the wider health systems.

Ramadhani Abdallah Noor, a Tanzanian physician and research associate at the Harvard School of Public Health, says that while the early days of funding were characterised by turf wars between vertically-organised, disease-specific initiatives, that is no longer the case — at least in Tanzania. “We had suffered from that — we felt that we were getting a lot of these vertical programmes, and the HIV treatment programme people would not talk to the TB treatment programme people,” he says.

“I think that was the immediate result of how the funding mechanisms worked. These programmes, even though they’re highly likely to be going to benefit the same people on the ground, were funded by different sources, and every funder’s wish was to be able to follow down to the last datapoint what the impact or outcome had been.”

That has changed, Noor says, and a recent programme, funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) led to a broader improvement in capacity in the country. Health workers that were trained by the programme have been absorbed into the national health system; facilities have been built and maintained that have wider uses.

“There has been a very interesting spillover effect into other avenues… such as mother and child clinics. It has brought up very interesting investments in terms of laboratories and diagnostics. It has brought up interesting investing in terms of data management systems, monitoring and evaluations,” Noor says. “All of that, were it not for the HIV [programme], would not be possible to attain at this speed.”

Going it alone

Rwanda’s health system does benefit from international public sector investment, but in the immediate aftermath of the genocide, Rwanda’s healthcare system actually received comparatively little international aid — in fact, in 1995 the country attracted less global spending on health than anywhere else in sub-Saharan Africa.

Around 20% of the Rwandan government’s budget is spent on healthcare; half of that comes from international sources. However, Rwanda has managed to set many of its own priorities, based on the systems of governance and equity that the country tried to instil in the aftermath of its civil violence.

“It was a political and philosophical decision to promote gender equity, geographical equity,” Binagwaho says. “Those principles of governance were what we built the health system on.”

Investments at all levels of the health system, from the recruitment of health workers through to the siting of hospitals, are done after consultation with communities, giving them a stake in the system’s development. Binagwaho herself inhabits this notion of collective consultation, hosting a weekly #MinisterMonday conversation with constituents on Twitter.

While she admits to being under the same pressure from donors to align the country’s strategy with those of her funding partners, Binagwaho says that their ideas have to put to local stakeholders.

“If the donor says ‘we advise you to do that’, we listen. If the idea is good, we go back to the people and ask them.”

The best way to resist the creeping influence of donor priorities, she says, is simply to come up with your own strategy.

“If you have a better way, convince them. If you know what you’re doing, you’re very convincing.”

The Rwandan system is organised as a “pyramid of care”, which begins at the village level, where tens of thousands of health workers have been trained to serve local communities. Every 7–10 villages is organised into a cell, and above that every 7–10 cells sits under a sector administration.

At the sector level, health centres served principally by nurses and midwives take care of maternal and child health and other primary healthcare requirements. District hospitals, serving several sectors, have a minimum of 10 doctors, and above that, provincial hospitals serve specialist needs. Five referral hospitals in major cities have even higher levels of specialisation.

One striking feature of the system is its agnosticism over who actually delivers the services. From the bottom, up, private providers are integrated into the ‘pyramid’, paid for by the national health insurance system.

“There are already public, private and community partnerships all along the chain,” Binagwaho says. “The private sector is at the heart of primary care.”

Private sector

The PPP, or public-private partnership, is hardly a new concept in African healthcare. Governments, companies and the international public sector have tried — and in many cases failed — to structure deals to build hospitals, and sometimes entire healthcare services.

“I have to say, over the last decade we lost a lot of time and probably a lot of money trying to figure this out, when there can be very simple solutions of PPPs,” admits Farid Fezoua, the CEO of GE Healthcare Africa, which has been working on the continent for the best part of a century.

For most of that time, the company’s role has been to supply and maintain medical equipment. The company’s experience over the past few years has, however, been that governments and health ministries are moving away from trying to build hospitals or clinics, and coming to GE with more simply articulated problems: ‘we need to reduce maternal mortality’, or ‘we need a system of cardiac care’.

“Today, you see a totally different approach,” Fezoua says. “There is a pressure to solve issues, particularly around healthcare and education in the countries. Whether it’s the Arab Spring in the northern parts of Africa, whether it’s what we’re seeing in Nigeria or in East Africa, governments have to deliver these outcomes.”

This has translated into far more flexible partnerships. GE, which Fezoua says has no interest in operating the clinical side of healthcare, can build local and international consortiums, bringing in finance from the International Finance Corporation or the World Bank to fund construction and ongoing maintenance, in an almost out-of-the-box solution.

“That is PPP. You don’t need to have a law to do that, you can do it on an agile basis,” Fezoua says.

“If you came six years ago with that proposition to a government in Kenya or Nigeria, even Algeria, they would have said no, healthcare is not for the private sector; public healthcare is a national mission. They would not have been open to that.”

Ideological debates still rage across developed and developing markets about the extent to which the private sector should run health systems. In the US, the Obama administration has fought a torrent of criticism from the political right in its battle to roll out state-backed, universal healthcare. In Western Europe, where basic healthcare is widely seen as a public good, belt-tightening by governments has reinvigorated calls for greater private sector provision.

For the majority of Africans, the reality is that healthcare is already a private sector experience. Across most of the continent — with a few exceptions in Southern Africa — out-of-pocket expenditures comprise more than 85% of households’ spending on health. Most of this goes into primary healthcare — a huge, but often unappreciated sector.

Primary healthcare

As York Zucchi told a TEDx talk last year: “Primary healthcare is the biggest industry that you’ve never heard of.”

Zucchi, a Swiss investor, is the founder of Hello Healthcare, one of Africa’s fastest-growing health businesses, with offices across the continent.

Primary healthcare in sub-Saharan Africa is overwhelmingly delivered by small clinics, often run by one or two nurses in or near the communities they serve, Zucchi says.

“While in the hospital sector you have very large hospital groups and doctor practices, primary healthcare is generally speaking an extremely fragmented industry,” he says. “You’ve got a big market, a big segment, a big need, but no economies of scale when it comes to purchasing power, when it comes to marketing. You’ve got a lot of entrepreneurs and SMEs reinventing the wheel constantly.”

In South Africa — where Zucchi is based — township clinics that charge R38 ($3.30) for a consultation can co-exist and compete with free public clinics that are overstretched — and a R300 bus ride away. These clinics, he says, need to work efficiently in order to see as many patients — clients — as possible.

“We’re seeing a proliferation of service providers, nurses who are taking the entrepreneurial route,” he says. “This is, for me, phenomenal news. It means there is an awakening of the potential of delivering healthcare in a way which is also controlled and incentivised.”

The problem is that they lack economies of scale, and struggle to raise the finance for expansion.

“They’re all very small businesses, and they’re all struggling to survive. They’re trying to survive every day. They work for patients, they try to find clients. They don’t have time for strategic discussions, for mergers and acquisitions, consolidation, for synergetics, for all that crap you learn in MBA school.”

Hello Healthcare’s innovation, Zucchi says, is “a stupid thing. It’s nothing more than some companies working together. It’s not rocket science.”

The company is trying to aggregate this fragmented landscape of primary healthcare provision, giving individual nursing practices and small clinics a single back office, freeing them from many of the ongoing costs of administration and marketing. The company also links these providers to potential corporate clients, helping them to tender for contracts to run clinics for large employers, such as mines and power stations.

“My hope is to make a little bit of an impact and attract more people into the sector. I believe that the more entrepreneurs there are, the more funding that will come, and the more competition. Usually, with a few exceptions, the more competitors, the lower the prices and the better the service.”

Affluenza

Bringing up the quality of African healthcare will mean more than simply increasing the scale of providers, and the end of the ‘emergency’ phase in African healthcare creates new challenges.

Disease eradication and treatment is likely to be a priority in remote and rural areas, but the continent is rapidly becoming an urban one. At current rates, by 2030 more than half of all Africans will live in cities, and their healthcare needs — and concerns — will change.

With an urban lifestyle comes an urban diet, and the so-called ‘lifestyle diseases’, such as diabetes, cardiac and liver complaints — and cancer. The World Health Organisation forecasts that by 2030, more people will die from such non-communicable diseases than from communicable ones. In some ways this is progress — demonstrating that the continent is, slowly, winning the fight against HIV, malaria and other diseases. However, few major African cities have advanced oncology or cardiac facilities.

“Today, if you look at a country like Kenya or Tanzania, or even Nigeria, you don’t have advanced means of detecting simple breast cancers or prostate cancer, and even less ability to cure cancer through chemotherapy or radiotherapy,” says GE’s Fezoua.

“The governments, even the private healthcare providers, are even more handicapped, because the countries in Africa received a lot of support in alleviating the burden of things like HIV in Africa, but fighting cancer is not something that they had planned.”

“What I think we’re going to see in Africa, particularly as we get a handle on some of the communicable diseases… is that we’re going to unleash the effects of the non-communicable diseases that are being largely curtailed by the communicable diseases,” says Ernest Darkoh, a medical doctor and public health expert.

Darkoh is co-founder of Broadreach Healthcare, which advises governments and businesses on developing healthcare models.

He says that healthcare systems in sub-Saharan Africa — and in the rest of the world — are currently ill-prepared to serve the needs of populations with a high incidence of chronic diseases, which require complex, ongoing care and a greater emphasis on the patient’s own capacity to manage their health outcomes.

“We’re just not set up for it in terms of the expertise, in terms of the technology. And even more fundamentally, the follow-up systems that are required,” he says.

“It’s new territory for the medical profession… That’s where I think we need as a medical profession to rethink and refocus the very essence of our healthcare model.”

This story first appeared on the cover of the March edition of African Business magazine.