How we envision change
Imagine a healthcare system infused with trust – one in which we have created a circle of trust by connecting demand, supply, policy, and investment. Funding would bring security and the potential for improvement. Standards would provide reliability and inspire quality. And with a trusted system, more people would be willing to pre-pay for healthcare. This is a far cry from what we see today. Health systems in sub-Saharan Africa are suffering from chronic underfunding. Every year, 11 million people are pushed further into poverty because of high, often unexpected healthcare expenses. And quality of care is insufficient, leading to 5 million deaths every year. As long as healthcare is underfunded and funds are not effectively spent, quality of care will not improve. At PharmAccess we believe a holistic approach will enable these health systems to rebuild a foundation of trust. Mobile and digital technology opens a world of opportunity to bring transparency and accountability, leading to more certainty for all stakeholders. And data and digital tools enable better decisions throughout the healthcare system, from policy maker to patient, giving people confidence. PharmAccess is working towards a new future for healthcare in sub-Saharan countries, making inclusive health markets a reality. Our vision is a world where everyone can access basic, affordable, and quality healthcare services, and we challenge the notion that people in lower income countries are inevitably left behind. Largely financed through The Ministry of Foreign Affairs of the Netherlands, and complemented by corporate, private, and institutional donors, we work primarily with African public and private sector parties, as well as Dutch businesses such as Philips and Luscii, to provide (financial) access to better care through digitalization. More than 50% of healthcare is provided through the private sector in our focus countries – Nigeria, Ghana, Tanzania and Kenya – and we are working with the sector to close the gaps in care. But these collaborations are also important for testing and starting innovative approaches on the demand and supply side: together, we show that a model works, then we can scale up and grow to public use. Figure 1. Creating a circle of trust by connecting demand, supply, policy and investment
PharmAccess supports demand-side financing programs, builds best practices, and delivers technical support to improve inclusive health insurance and prepayment mechanisms. Stable demand relies on the reliable supply of quality health services, so on the supply side, PharmAccess increases the investments in healthcare providers, led by Medical Credit Fund (MCF) and improves the quality of care, through initiatives led by SafeCare, both part of PharmAccess . The aim is to attract more resources and use these more efficiently and effectively, leading to an upward spiral of trust among stakeholders. We also partner with Investment Funds for Health in Africa (IFHA), a private equity impact fund dedicated to (equity) investments in private healthcare companies in Africa, and CarePay – a PharmAccess innovation and spin-out, and our preferred partner for rolling out insurance schemes and gathering valuable data. CarePay developed a mobile and cloud-based platform called M-TIBA, which is a digital connector between insurers, donors, healthcare providers, and individuals that connects over 4.6 million people and 4,800 public and private healthcare providers in Kenya and Nigeria. Digitalization is a key element of our approach. Through the latest advances in mobile technology and data analytics, we are now at the forefront of value-based healthcare models. Patients are often powerless in the current system, but with digital health innovations, we can place the patient in control of their own healthcare journey. It helps unify funding streams and enables the more efficient application of that funding – we can use mobile technology to reach more people at marginal cost. This is how we can help demand to meet supply. While we begin with the private sector, true scaling requires collaboration with the public sector. Currently, governments do not prioritize the effective spending of tax and donor funding enough to improve healthcare delivery and reduce out-of-pocket expenditure for low-income groups. Patients cannot afford health insurance, making subsidies for the lowest-income groups vital. With advocacy, research, and learning, we support governments and other stakeholders in our focus countries. We work towards the wider implementation and replication of proven best practices to strengthen health systems and promote digitalization and data as a common good. Although this brings clear benefits, there is also resistance, especially around the creation of transparency and reduction of fraud. We are already demonstrating the possibilities to strengthen health systems in sub-Saharan Africa, but to drive change, we need the (political) will from the entire ecosystem. We would like to continue collaborating with Her Majesty on this, to gain the support of key stakeholders for the change needed to enable greater access to quality care for everyone.
Where we are today: Healthcare in sub-Saharan Africa
Although progress was being made towards UHC, the COVID-19 pandemic has halted it [1]. Not only did the disease directly lead to 15 million deaths and reduce global life expectancy, it also reduced access to healthcare more indirectly as a result of the economic crisis. And there were indirect impacts too: for example, the lockdowns led to an increase in teenage pregnancy and hampered the supply of medications. The health and economic impacts of the pandemic may have led to higher inflation and greater financial constraints, preventing people from accessing care. Many are already paying for care out-of-pocket, and according to the UN [2], their “financial hardship is likely to worsen further, particularly for those already disadvantaged.” Political challenges and opportunities Changes in the global and local economies and political shifts affect healthcare systems around the world. Each country has a unique set of circumstances, providing challenges but also opportunities. For example, while there is a danger that new governments could stop existing programs, changes in political power can also accelerate progress. We continue to partner with governments in the region to support greater access to quality healthcare through financial inclusion and data as a public good.
Sub-Saharan African countries need efficient digital solutions and investment now more than ever. As the political and economic climate continues to shift across the region, we will continue our work to leave some subsidies intact for the most financially vulnerable, like the Kenyan county government’s Linda Mama and Marwa (co-created by PharmAccess), and make inclusive health markets a reality. More healthcare funding is vital, but alone it is insufficient – we also need to ensure the smarter use of the available funding. Our interventions aim to increase trust by putting patients at the center of healthcare through digitalization, reducing transaction costs and increasing transparency and accountability. We will look at these interventions in more detail throughout this report.
- Poverty rate: 11.3% [3]
- Total Health expenditure (as % of GDP): 3.49% [4]
- Health expenditure per capita: $ 40 [5]
- Maternal mortality rate: 308 (per 100,000 live births) [6]
- 8.6% of population is covered by health insurance [7]
GHANA - The currently soaring inflation rate, caused by depreciation of the cedi and an increase in the price of commodities, means people are facing unmanageable household and medical costs, and businesses and financial institutions cannot invest in healthcare. This results in facilities facing financial challenges due to extensive delays in the payment of claims through national health insurance, as well as the increasing cost of drugs. Efforts will be needed to maintain the 50% of Ghanaians covered by national health insurance. An emergency fund could be established to avoid reversing progress made towards UHC.
- Poverty rate: 40.1% [8]
- Total Health expenditure (as % of GDP): 3.03 [9]
- Health expenditure per capita: $ 71.74 [10]
- Maternal mortality rate: 917 (per 100,000 live births) [11]
- 3% of population is covered by health insurance [12]
NIGERIA – The situation in Nigeria is particularly challenging – the country has the worst health figures but the least money. 63% of people living in Nigeria (133 million people) are “multidimensionally poor.” The current government’s continuous borrowing raises concerns, unemployment is high (35%), inflation is high, and distrust is growing between the political elites and the public. Currently 1% of the consolidated revenue of the Federal Government of Nigeria is budgeted to cover healthcare costs for those who cannot afford it, which is a growing number of people. A new tax on sugar-sweetened beverages aims to bolster this, a move which was supported by PharmAccess. However, concerns remain whether the funds will reach those that need it most.
- Poverty rate: 26% [13]
- Total Health expenditure (as % of GDP): 4% [14]
- Health expenditure per capita: $ 40 [15]
- Maternal mortality rate: 524 (per 100,000 live births) [16]
- 32% of population is covered by health insurance [17]
TANZANIA – The Tanzania government tabled a mandatory health insurance act in September 2022. The act will allow for both private insurance companies and public health insurance agencies to provide a defined minimum benefit package. The act creates a solid basis for UHC and creates new opportunities to support the government on this journey. Zanzibar has launched a digital health strategy and is expected to pass a health insurance bill in February 2023. The bill will empower the Revolutionary Government of Zanzibar to create the Zanzibar Health Services Fund to finance the archipelago’s social health insurance program. The bill includes provisions for the involvement of the private sector and mandates the creation of a Health Equity Fund (HEF), which will be used to finance premiums for the lowest income groups. This departure from the existing concept of ‘free care’ is a positive development. People often need to turn to private vendors that overcharge, because public facilities are unable to provide adequate services due to insufficient funding.
- Poverty rate: 41.9% [18]
- Total Health expenditure (as % of GDP): 4.59% [19]
- Health expenditure per capita: $ 83.41 [20]
- Maternal mortality rate: 342 (per 100,000 live births) [21]
- 19.8% of population is covered by health insurance [22]
Kenya – The burden of financing public debt is now high – estimated at 69.1% of GDP – and the rising public wage bill now stands at 48.1% of government revenue. At 24.3%, out-of-pocket spending on healthcare remains a major barrier to accessing health services in Kenya. However, President William Ruto continues to prioritize universal health coverage (UHC), including with a social health insurance system that will comprise mandatory national insurance and private insurance as complementary cover. The government will digitize 85% of its services, paving the way to a health-integrated information management system to enable every person in Kenya to own and control access to their health records on their phones [23].