Reading statistics about healthcare in Africa is not for those of a pessimistic disposition. A recent report suggested that to make Africa’s healthcare system fit for purpose about 90,000 physicians, 500,000 nurses, and 300,000 community health workers will be needed, in addition to an extra half a million hospital beds. It’s an area that Invest International believes it can make a real impact and change people’s lives for the better. Invest International’s lead on health, Jasper Klapwijk, explains.
Invest International’s lead on health is Jasper Klapwijk. After a successful career in real estate, shipping finance and banking, he joined FMO, the Dutch development bank and on his first trip to Africa to check out one of their projects he fell in love with the place.
“I thought it was so cool. The people, the atmosphere, the weather. It was so different from the planned life we all lead, working from nine to five or six in the evening, everything in Africa happens upside down,” he says. “But things still get done. “But above all else I was struck by the positive impact you can create through healthcare.”
At any one time there are between 20-25 projects in development, and they take many different forms. The challenges are multi-layered and need a holistic approach – it’s no good having a well-equipped clinic if you don’t have the trained staff to run it or it’s too far away from the people who need it. While investing in primary healthcare helps those at the various levels of the health pyramid, prevention and a growing use of technology are also an important part of the mix to offer hope to the millions of people on the sub-continent who struggle to get access to even the most basic medical services and medicines.
Telemedicine, the remote analysis of medical imaging, at times even AI based, remote expert support to medical staff, and video consultations with specialists are all exciting areas that have the potential to change the lives of millions of Africans. But there’s a long way to go.
By many measures, and on many levels, sub-Saharan Africa has the worst healthcare in the world. Few countries – according to the International Finance Corporation (IFC, part of the World Bank) – are able to spend the $34 to $40 a year per person that the World Health Organization considers the minimum for basic health care.
By many measures, and on many levels, sub-Saharan Africa has the worst healthcare in the world. Few countries – according to the International Finance Corporation (IFC, part of the World Bank) – are able to spend the $34 to $40 a year per person that the World Health Organization considers the minimum for basic health care.
About half of Africa’s health products and services are delivered by the private sector and it’s not just the rich who pay for their healthcare. Parents with minimal income might have to take their sick child to a private clinic as it’s often the only way they can be seen by a doctor or nurse. The private sector fills a crucial gap, existing due to either a non-existent or a non-functioning public health system. Informal workers, and others at the base of the health pyramid, have to pay out of their own pockets to get medical help, a challenge for many if the treatment involves more substantial medical procedures.
For Jasper it’s in primary healthcare that the biggest strides can be made, and the biggest impact can be delivered. “Everyone has a right to healthcare – so it’s not only that you provide clinics that are equipped and stocked, but that it’s in reach so you don’t have to travel too far, and you don’t have to pay for it so you don’t fall into poverty,” he says.
“If you were African and had to go to the clinic today you would be walking for four hours, sit in a waiting room and then walk back for four hours, you won’t be working that day. They have no days off. They would just not earn any income for the day.
“So, the flip side is do I go to the doctor or are we going to eat today? Of course, they don’t go to the doctor.”
Although Invest International’s primary impact measures are around SDG 8 (decent work and economic growth) and SDG 13 (action on climate) – SDG 3 is a secondary focus. While SDG 3 is about good health and wellbeing, SDG 3.8 in particular focuses on minimising the financial impact of health on the world’s poorest. In addition, a population that is not healthy will not be economically active. Health is therefore a key driver for SDG 8.
In a good example of the impact that can be made by investing in primary care, Invest International, Amref Health Africa and Royal Philips have teamed up to form the Partnership for Primary Care (P4PC) in Kenya. A pilot programme working with the Makueni County Department of Health Services shows how a partnership between the public and private sectors can deliver results and improve the lives of people living there.
The ambition is to improve or set-up 80 clinics in the county. In a pilot project to test out the feasibility of the proposal, three communities in Makueni county were targeted with each of the partners taking responsibility for particular aspects of the project. Philips was responsible for the technological upgrade, as a health NGO, Amref’s role was in educating the local populations about the new facilities, and the local health service was responsible for the buildings and staffing.
In a good example of the impact that can be made by investing in primary care, Invest International, Amref Health Africa and Royal Philips have teamed up to form the Partnership for Primary Care (P4PC) in Kenya.
The pilot project showed the potential of this kind of approach and equally importantly demonstrated that there is a feasible business case for this kind of Public Private Partnership (PPP) approach.
Invest International’s role has not only been in helping put together funding, but the team also played an active role, providing business expertise, collaborating on the ground with the project team as a co-developer, and working on different models that could attract other investors and sources of funding. Other funders” in this case also meant the involvement of the Public side of Invest International for the potential viability gap funding. Consequently, DRIVE TA – a government to government grant arrangement that comes with technical assistance – was used to provide the county with PPP advisors that played a crucial role in the assessment of the opportunity by the county.
Another important piece in the jigsaw is the referral system. “We have to get people to go to their GP first. In many African countries people just go to the hospital. They do that because they know when they get there the hospital will have the staff and in general the medicine will be there.”
Education is another weapon in the fight against ill health. “Can we keep people out of the system in the first place? The role of community health workers and volunteers is crucial. They are out there telling pregnant women they have to go to the clinic or teach them about handwashing and other basic health measures. “There’s a lot of misinformation about what is and isn’t healthy, what people should and shouldn’t eat so these healthcare workers play a very important role.”
Building hospitals and secondary healthcare services is obviously important in tackling cancer, cardio-vascular diseases and other high intervention illnesses that call for sophisticated equipment and highly trained medical teams. That’s why Invest International is looking at how they can get hospitals built in countries like Ethiopia, Tanzania, Bangladesh, Burkina Faso and the like.
But it’s in primary healthcare that Jasper believes the biggest impact can be made. “The return on a dollar invested in primary healthcare is much greater than if you invest in cardiac, oncology or other secondary healthcare investments,” he says.
As Jasper explains: “Firstly, primary healthcare plays an essential role in prevention with a focus on health as opposed to healthcare. With the burden of disease changing, lifestyle diseases like hypertension and diabetes need early attention.”
“Secondly, by investing in primary healthcare, capacity is freed up in the hospitals where basic services are not designed to be provided but nevertheless, people tend to go to the hospitals as they are better equipped and stocked and as a result, clog up the system.”
“Thirdly, it is also the level where eHealth solutions can accelerate impact most.”
For Jasper it’s in primary healthcare that the biggest strides can be made, and the biggest impact can be delivered.
“Everyone has a right to healthcare – so it’s not only that you provide clinics that are equipped and stocked, but that it’s in reach so you don’t have to travel too far, and you don’t have to pay for it so you don’t fall into poverty,” he says.
Another important piece in the jigsaw is the referral system. “We have to get people to go to their GP first. In many African countries people just go to the hospital. They do that because they know when they get there the hospital will have the staff and in general the medicine will be there.
“But if you sit in a waiting room in a hospital it costs five times as much than if you sit in a waiting room in a dispensary. Even if we work on a hospital project our conversations with governments include talking about whether the hospital is a stand-alone facility or genuinely part of a referral system.”
But the real game-changer in all this is probably going to be technology – and it’s significant that nearly every project Jasper is involved in has an e-health component. With the Netherlands being home to one of the world’s leading health technology companies, Philips, telemedicine and ground-breaking technological innovations can potentially open up an exciting range of opportunities for Invest International to achieve its mission to deliver Dutch solutions to global challenges.
While the work on the Partnership for Primary Care in Kenya is just one good example of harnessing expertise from different sectors to deliver workable solutions, two other projects demonstrate how Invest International is looking to technology to tackle the challenge of making an impact on Africa’s health services.
Invest International plays a crucial role not only as a source of finance and creator of partnerships, but also in making sure that the technical solutions are economically viable. “One crucial aspect of our role is that we are the reality check. Can they turn the idea into a business model. Is it possible to scale it up? Who is going to finance it?”
Invest International provided 122,600 Euros through DGGF to implement an artificial intelligence in Ghana developed by the Dutch company, Delf Imaging Systems for the detection of Covid-19 cases. This was a system of set up boxes that were added to an earlier introduction of 55 X-ray machines which was supported by ORIO, (the predecessor to DRIVE).
In addition, Invest International made 215,000 Euros available for a cloud-based AI tool that can analyse X-ray images uploaded to a remote server which in turn provides a result in the form of a score and heatmap image back to the requesting device increasing accuracy and reducing the need for intervention by radiologists and providing triage analysis for COVID.
Also in Ghana, Invest International helped PharmAccess foundation with the roll out of the Covid-19 Monitor – a digital ecosystem service that integrates the use of a Dutch Luscii mobile application and a remote care centre at the University of Ghana Medical Centre which provides remote information to prevent people with Covid-19 symptoms to visit clinics, limiting the spread of the virus and to provide information on the spread of the virus.
A lot was learned from the rollout, and as the parameters of Covid changed it was decided in conjunction with other partners to convert the application into a remote diabetes and hypertension monitoring tool. It could turn out to be a valuable weapon in the fight against non-communicable diseases in Africa where treatment rates for hypertension (15% for women and 12% for men) are among the lowest in the world. The further roll out of the tool is being funded by NORAD, the Norwegian Agency for Development Cooperation.
All these case studies demonstrate the crucial role Invest International has to play not only as a source of finance and creator of partnerships, but also in making sure that the technical solutions are economically viable.
“People can sometimes get carried away with the technology and the amazing things it can do,” says Jasper. “And one crucial aspect of our role is that we are the reality check. Can they turn the idea into a business model. Is it possible to scale it up? Who is going to finance it?
“We are here to look at a project with a financial lens. We have to ask the tough questions to make sure that there is a tangible return on investment. But at the same time, we need to make sure that we understand the industry with its challenges and opportunities so that we can select the right projects and project partners to support.”
It’s clear that there’s an exciting future ahead, and already inroads are being made into some of the big issues around healthcare in Africa. But because of Invest International’s unique mission to invest in projects that contribute to the Dutch economy, it does mean that sometimes there are tough choices to be made.
And thanks to their efforts so far, there is a huge potential health benefit for millions of Africans which in itself is a cause for optimism rather than the pessimism of the headline statistics.
