Healthcare in Africa
Sub-Saharan Africa accounts for 11% of the world's population, 24% of the global disease burden and bears 44% of the world's communicable diseases. Nearly half of the world's deaths of children under five take place in Africa. Yet, less than 1% of the global health expenditure is spent on the continent. Because public resources are severely limited, the private sector plays a significant role in providing healthcare. However, its potential is not fully utilized.
The private health sector in sub-Saharan Africa is fragmented and quality can be inconsistent. However, the sector has the important role of providing approximately 50% of all care in the region. The public health sector is often overburdened and struggling to provide a satisfactory level of care due to limited public resources. The vast majority of the region's poor people, both urban and rural, therefore rely on private healthcare. The growing population within the region will further drive the demand for affordable, quality basic healthcare services. But, at the same time, there is no investment capital available to allow private healthcare facilities to expand and improve their services.
Particularly small and medium-sized healthcare facilities (Health SMEs) find it difficult to attract investment capital, while the demand is substantial. Health SME's are often not able to meet banks' requirements for annual statements, collateral and business plans. They lack business skills, have no credit history and are unable to cover the high costs of capital charged by banks and investors to compensate for uncertainty and risk. The Medical Credit Fund was established to bridge the gap between demand for and supply of capital.
The MCF works at both sides of this gap. It works with healthcare facilities to strengthen their business case, administrative capacity and improve the quality of their medical services. This facilitates local banks to lend to Health SMEs at a lower risk profile. As a result capital provision is brought within reach of the Health SME's and lays the foundation for future servicing of these facilities by banks without external support. The MCF thus triggers and leverages investments by local capital markets and helps developing the private healthcare sector into a distinct asset class. In November 2010 MCF won the G-20 SME Finance Challenge award, which was presented to its chairman by president Barack Obama during the summit in Seoul.
The Private Healthcare Sector
Private healthcare facilities serve about 50% of all Africans seeking care. The sector is composed of for-profit commercial providers, and not-for-profit social or faith-based providers. Africans seeking care at private facilities represent all income groups and include the lowest quintiles of the population.
The potential of the private healthcare sector is now widely recognized by African governments as well as the major donor organizations and development banks. This recognition does not necessarily translate into increased resource allocation to private healthcare facilities, even though the demand for investment capital has been calculated at between USD 11 and 20 billion for the next decade.
Partly the lack of investments can be attributed to the general weak investment climate in Sub-Saharan Africa where institutions are weak and transaction costs are high. At the same time a remarkable uptake of investments in Africa can be noticed. Many countries show sustained economic growth, political stability has improved and the incidence of armed conflict has declined. Various economic sectors have indeed benefited from increased local and foreign investments. But private health is not among them, especially not the Health SME's: primary healthcare providers that serve low-income groups, while these make the majority of Africa's healthcare market. Investors and banks to date are reluctant to provide financing as the prevailing risks are unknown and considered too high.
As a result, the sector is very under-served in terms of access to capital. And if investments in private health are made at all, they come with levy high surcharges and mark-ups to cover all unknown risk. Not many healthcare providers are able to absorb those extra costs of capital.
Health SMEs constitute the vast majority of private healthcare providers in terms of doctor-patient contacts. And they represent the segment of the private healthcare market that is most underfunded. The small and medium enterprise segment covers a wide variety of organizations: smaller hospitals, diagnostic centers, health centers, dispensaries, maternity homes, health shops and nurse-driven clinics. It is there where most Africans seek care if they decide not to visit a public facility.
Health SMEs are identified as the segment that presents most of the investment opportunity of the USD 11 - 20 billion. Two-thirds of SMEs would need additional capital below USD 250,000. And it is especially these Health SMEs that are cut off from investments because the risks are considered too high by investors.
These risks relate to both financial and medical reasons:
Investors/banks have limited knowledge of the specific features of the private healthcare sector. There are few investment benchmarks to go by. Revenue streams are erratic due to the high dependency on out-of-pocket payments in health, which may affect the business case of private care providers. Also, in most cases, providers' administrative capacity is weak and do not have a credit history.
In most countries there are currently no defined medical standards and measurement of medical quality. Therefore there is no information on medical performance, providers cannot be compared and the impact of investments in healthcare provision cannot be monitored and measured.
The lack of investment capital prevents healthcare providers from investing in their facilities; they face challenges growing their businesses, upgrading their medical equipment and departments, and training and employing more skilled staff.
The MCF Target Market
Health SMEs are the chosen target market for the MCF. Investment needs are highest and the prospect of social and medical impact is highest in this segment. Given the challenges mentioned, this is not a segment ready for investment just like that. It is a segment where prospective borrowers need to be prepared to borrow from the local capital market and where investors need to gain experience to feel comfortable enough to see the potential of an emerging asset class.
That is the reason the MCF needs its technical assistance program. Its business advisors work with Health SMEs to reconstruct annual statements, propose efficiencies in management and operations, scan the market for growth opportunities and finally produce a convincing business plan. And its quality advisors work with the same SMEs to install or upgrade clinical procedures and protocols, improve performance areas and prepare for quality assurance through SafeCare certification and accreditation.
It is these activities that help make Health SMEs bankable. Not all, but the vast majority of participating Health SMEs indeed make the threshold. They do access a modest first loan and a larger second one. First generation lenders in the MCF Program have seen their business and quality performance increase. They attract more patients, provide better services and are in better financial shape than before.
The Medical Credit Fund mainly operates in the district hospital, primary health center, basic health center or health shop/nurse clinic segment of the private healthcare market. These are the segments where Health SMEs are active.
Vision, Mission & Objectives
The vision of the MCF is to enhance the provision of affordable quality healthcare services in Sub Saharan Africa to low-income Africans.
The mission is to enable primary health care providers in Africa to access investment capital so they can improve the quality of their services and expand their facility.
The objectives are to provide access to loans from local banks for around 2500 health care facilities, complemented with a comprehensive technical assistance program on quality improvement and business planning leading to external evaluation (SafeCare) of the facility's performance.
Governance and Management
The Medical Credit Fund was established as a not-for-profit foundation under Netherlands' law in 2009 by PharmAccess International in association with the Aids Fonds and De Grote Onderneming (DGO). Medical Credit Fund has been granted ANBI status by the Dutch Tax and Customs Administration and is domiciled in Amsterdam.
Arjan Poels, Managing Director
Bart Schaap, Finance Director
Dorien Mulder, Investment Manager
Tom Bouma, Senior Financial Analyst
Evelyn Gitonga, Director East Africa
Fisayo Okunsanya, Director Nigeria
Derrick Ewudzie-Odoom, Country Manager Ghana
The Executive Board of Stichting PharmAccess Group Foundation operates as Executive Board of Stichting Medical Credit Fund.
Onno Schellekens, Chief Executive Officer
Monique-Dolfing Vogelenzang, Chief Operations Officer
Jan Willem Marees, Chief Financial Officer
Stichting Medical Credit Fund is supervised by the Supervisory Board of Stichting PharmAccess Group Foundation.
Max Coppoolse, Chairperson
Pauline Meurs, Vice Chairperson
Willem van Duin
Peter van Rooijen