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. It is domiciled in Amsterdam, governed by a Supervisory Board.
Monique Dolfing-Vogelenzang, Managing Director
Monique Dolfing-Vogelenzang prepared the launching of the Medical Credit Fund at PharmAccess International and is the Managing Director of the Fund. Previously she has held senior commercial and business management positions in the private sector.
John Simon, Senior Director
John Simon has been involved in setting up the Medical Credit Fund and more recently joined as a Senior Director. He served as US Ambassador to the African Union and Executive VP of the Overseas Investment Corporation (OPIC) and founded Total Impact Capital. He is responsible for investor relations and oversees MCF's credit process and performance
Bart Schaap, Director Finance
Bart Schaap came to the MCF as Director of Finance. He is a monetary economist and worked in the financial sector as risk manager and credit finance specialist in both developed and emerging markets.
Dorien Mulder, Investment Manager
Dorien Mulder is Investment Manager working on product and deal development. She is a medical doctor with an MBA and worked in hospital management, pharmaceuticals and health infrastructure development.
Tom Bouma, Senior Financial Analyst
Tom Bouma is an experienced SME consultant. He is the Fund's Senior Financial Analyst, responsible for all loan appraisals processes, and provides training to MCF's Technical Assistance partners in the field of business planning.
Joost Zijlmans, Financial Manager
Joost Zijlmans has a controlling background and worked for PharmAccess for four years before joining the Medical Credit Fund. In his current position, he is responsible for the Budget & Control Cycle of the Medical Credit Fund's loan portfolio and technical assistance programs.
Nada Coici, Portfolio Analyst
Nada Coici started as an intern and then stayed on to work as a portfolio analyst. Before joining the Medical Credit fund, she graduated from Utrecht University with a background in International Financial Economics. Currently, she is in charge of loan portfolio analysis and process flow monitoring.
Evelyn Gitonga, MCF Director East Africa
Evelyn Gitonga is the Business Development Manager for East Africa, stationed in Nairobi, Kenya. With a long-standing experience in banking, she is responsible for managing the program and partnerships and developing the portfolio in East Africa.
Alfred Mutuku Timothy
Ewout Irrgang, Technical Director Tanzania
Ewout Irrgang is Technical Director of PharmAccess in Tanzania and manages the MCF program. He is an economist and political scientist who worked in Dutch politics before joining PharmAccess. He manages the MCF and bank relations in Tanzania.
Patience Imoukhuede, MCF Director West Africa
Maxwell Akwasi Antwi, Country Director Ghana
Maxwell Antwi is the Country Director for PharmAccess in Ghana, managing the MCF Program. He is a medical doctor with a rich background in Health Service Management, Public Health and Obstetrics-Gynecology practice in both private and public health sectors.
Samuel Akuffo Newman
Hansen Yaw Asare
Max Coppoolse - Board Member - Chair
Max Coppoolse graduated from the University of Amsterdam with a master's degree in industrial psychology. He had several senior positions at amongst others Unilever, KPN-Philips and Libertel-Vodafone. In 2003, Max became COO of PharmAccess Foundation, and was responsible for all operations of the Foundation. Now, Max is Managing Director of the Investment Fund for Health in Africa (IFHA), which he co-founded in 2007.
Ben Christiaanse - Board Member
Ben Christiaanse has over 40 years of banking experience. In 2006 he was appointed as CEO of National Microfinance Bank in Tanzania. He developed NMB into one of the largest financial institutes of Tanzania, and successfully managed an IPO of part of the share capital of the bank in 2006. In 2010 he established his own consultancy that focused on financial institutes in developing countries. Ben now serves as a board member in several African Banks and is member of the supervisory board of two Dutch organizations.
Willem van Duin - Board Member
Willem van Duin started his career with Achmea in 1987. Before he was appointed in the Executive Board in 2004, he held various positions at Holding level as well as board positions. He holds board positions in the Dutch Association of Insurers (Verbond van Verzekeraars, vice-chairman), VNO-NCW (the Dutch employers' organization) and National Cooperative Council. Willem is currently one of the vice-chairmen of the council of iFHP (International Federation of Health Plans) and chairman of the board of the European Alliance Partners 'Eurapco' (an association of European mutual insurance companies).
Wilfred Griekspoor - Board Member
Wilfred Griekspoor has been active in the governance and management of large-scale international health development efforts as Vice Chairman of Médecins sans Frontières Holland and as start-up Managing Director and later Chief Financial Officer of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. He is a former chair of the Van Leer Group Foundation. He currently serves on the Boards of the Access to Medicine Foundation, and the Infectious Diseases Institute in Uganda and is a lecturer and member of the Global Advisory Council of the African Leadership Academy.
Ruud Hopstaken - Board Member
Ruud Hopstaken has held executive positions at organizations like Buma/Stemra, PriceWaterhouseCoopers and the Amsterdam Medical Centre. Ruud is chairman of the Supervisory Board of GGNet (Institution for mental health care) and the Institute for Positive Health (IPH). He is also board member of various boards and committees within the health (insurance) sector.
Pauline Meurs - Board Member
Pauline is currently a Professor of Healthcare Governance at the Erasmus University Rotterdam and Chair of the Board of the National Council for Health and Society (RvS). She is the founder and Scientific Director of the Erasmus Centre for Health Care Management, which offers tailor-made postgraduate and executive programs for managers and CEOs of healthcare organizations. Among others, she is a member of the board of the University of Amsterdam and the Amsterdam Medical Centre.
Peter van Rooijen - Board Member
Peter Van Rooijen is the Executive Director of International Civil Society Support. He also serves on the Boards of i+solutions, the Amsterdam Health & Technology Institute and the Joep Lange Institute. He has been involved in HIV/AIDS since 1984, initially as volunteer, later as a psychotherapist and director of Care Services at the Schorer Foundation (Amsterdam). In 1992 he was the director of the Dutch National Committee on AIDS Control. From 1993-2005 he served as the executive director of Aids Fonds (established in 1986) and STOP AIDS NOW!
Kees Storm - Board Member
Kees Storm is current board member of Baxter International Inc., Pon Holdings B.V , Scripsit Holding (Eisma Media Group), Industrial Advisors EQT and Member Curatorium VNO-NCW. From 1993 to 2002, he served as Chairman of the Board of Aegon, a multinational life insurance, pensions and asset management company headquartered in The Hague, Netherlands. He was appointed to AEGON's Supervisory Board in 2002, and his term ended in 2014.