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Destination Universal Health Coverage: Can PPPs be the vehicle to get us there?

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PharmAccess Foundation’s journey in PPPs has shown significant promise and evidence of the organisation’s successful partnerships can be seen in the revitalised primary health centres in Lagos and Delta State. Photo source: PharmAccess Foundation

The best stories of growth in Nigeria have been private sector driven – whether it is in telecommunications, financial services or in infrastructure. So, why have we not felt the impact of the private sector in the health sector, especially on the frontlines of primary health care (PHC)?

Almost everyone in Nigeria has directly or indirectly experienced the catastrophic impact of emergency out-of-pocket expenses on healthcare. We can no longer keep on doing the same thing – and hope for different outcomes – it is time to think differently and do things differently. It is time for strategic private sector engagement.

We all agree that the desired destination is Universal Health Coverage (UHC), i.e. ensuring that everyone in Nigeria has access to quality healthcare. As defined by the World Health Organisation (WHO), UHC means that “all people and communities can use the promotive, preventative, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship“.


Image credit: Nigeria Health Watch
Countries that have made significant progress in reaching this goal have health systems that include functioning primary healthcare, with a trained health workforce, access to essential medicines and the requisite technology to perform their roles. Sustained financing is also available to the health system and the entire population irrespective of their economic status has access to quality health services. However, in Nigeria, how do we achieve this goal given our mixed and fragmented health system that encompasses the private and public sector? How do we ensure that no individual or family is impoverished by catastrophic health expenditure?

The current state of the Nigerian health sector
The Nigerian health sector has suffered from chronic underfunding, 72.24% of current health expenditure is out-of-pocket, leaving patients to bear the burden of funding their own healthcare. This has led to sub-optimal healthcare delivery with many of our health indicators below national targets and international standards. Eighteen years after the Abuja Declaration where African Union states pledged to allocate at least 15% of their annual budget to health, Nigeria continues to default. Low budget allocation (and it is reducing rather than increasing) has crippled the Nigerian healthcare system in many ways. We forget that a healthy population is truly the best insurance we can have for our economy to thrive. Several studies have shown that investing in health leads to economic development.

If primary health care provides whole-person care for health needs throughout one’s lifespan, not just for a set of specific diseases, why do we neglect PHCs in Nigeria? Why do we still have wards that have no functional PHCs? Why do Nigerians visit secondary and tertiary health facilities for illnesses that should be treated at the primary level? This is likely because the primary healthcare system has failed them.

The important role of the private sector
There are competing demands on Nigeria’s national budget and health has not been given sufficient priority, leaving it underfunded. In a recent speech by Christine Lagarde, Managing Director of the International Monetary Fund (IMF), she stated that the Nigerian economy will struggle due to low revenue generation, given the country’s tax-to-GDP. This will have implications on the country’s ability to direct sufficient resources at the health sector and there is little hope that more funds will be made available to strengthen our already weak health infrastructure.

The role of the private sector is therefore critical in enabling improved access to health for all. It is clear that our public health system faces limitations, as it is not able to meet the healthcare needs of the population. The private sector, however, has the capacity to provide the technical efficiency required to deliver health services. Engagement of the private sector has, therefore, become critical as with the growing population in Nigeria, the public health sector is overcrowded and slow to innovate. Many initiatives have been tried to bolster the health sector and public-private partnerships (PPPs) in healthcare have emerged as a possible vehicle to enable the advancement towards UHC.

Yet, this is not an easy space. It is littered with failed projects and lost investments. It requires extensive thought leadership – an area that we at Nigeria Health Watch partnered with PharmAccess Foundation to address through a recent health policy dialogue.

PharmAccess Foundation – Systems transformation through PPPs 
The private sector can play an important role in strengthening health systems in Nigeria. Through their expertise and capacity and PharmAccess Foundation has an integrated approach that focuses on the supply side of healthcare delivery, not just the demand side. The health policy dialogue on the 11th April 2019, organised by PharmAccess Foundation and Nigeria Health Watch, titled Disrupting health care – PPPs as a model adoption for health system strengthening in Nigeria” highlighted PharmAccess Foundation’s journey in revitalising primary health care centres in Lagos through PPPs. This is not PharmAccess Foundation’s first foray into PPPs, the organisation had worked with Hygeia Community Health Care and the Kwara State Government on a PPP to develop the Kwara State Community Health Insurance Scheme, with the aim of providing affordable access to quality healthcare through the introduction of subsidised health insurance.

 
“Quality is not a pass or fail process in our own books. It is about improvement”, Ms. Njide Ndili, Country Director, PharmAccess Foundation. Photo source: PharmAccess Foundation
The selection by PharmAccess Foundation of primary health care centres to revitalise first involved a geo-spatial mapping of existing facilities in Lagos. In the process, it became evident that there were many non-functional primary health care centres which still received an allocated budget to run. The PPP model adopted by PharmAccess enabled greater access to finance to enable the revitalisation of primary health centres – the frontline of healthcare access for more Nigerians. Realising that health facilities have struggled to access finance due to the stringent requirements put on them by financial institutions, PharmAccess established the Medical Credit Fund (MCF), which places money within the banks as guarantees, with the purpose of helping private healthcare facilities to access affordable finance and PharmAccess supported with capacity development. The effort as Ms. Njide Ndili, Country Director, PharmAccess Foundation, explained, was to provide loans at single-digit interest rates, compared to financial institutions with interest rates as high as 24%, making repayments easier and anchored on a model of sustainability.

“All health PPP projects must consider dimensions of quality including technical competence, access to services, effectiveness, safety, efficiency and continuity”, Dr. Ibironke Dada, Director of Quality at PharmAccess Foundation. Photo source: PharmAccess Foundation
In providing loans, PharmAccess Foundation also ensured that the healthcare services provided by such facilities met a minimum quality standard. To support the revitalised health facilities, PharmAccess Foundation introduced SafeCare, the only quality accredited standard for resource restricted countries like Nigeria. SafeCare standards were developed with Joint Commission International (JCI) and facilities receive their accreditation from the Council for Health Service Accreditation of Southern Africa (COHSASA). “Quality is not a pass or fail process in our own books. It is about improvement”, Ms. Ndili said while discussing SafeCare. “All health PPP projects must consider dimensions of quality including technical competence, access to services, effectiveness, safety, efficiency and continuity”, Dr. Ibironke Dada, Director of Quality at PharmAccess Foundation pointed out.

“Trust drives financial services. Trust drives lending. Trust is capital for the doctor and equipment supplier”, Mr. Olufisayo Okunsanya
Business Development Director of the Medical Credit Fund. Photo source: PharmAccess Foundation
Challenges funding healthcare in Nigeria
What drives the lending system? Trust. Trust. Trust. Trustworthiness matters in all financial transactions; healthcare transactions are not excluded. At the policy dialogue, Mr. Olufisayo Okunsanya, Business Development Director of the Medical Credit Fund, explained how trust is key between all stakeholders and in its absence, lending does not occur. “Trust drives financial services. Trust drives lending. Trust is capital for the doctor and equipment supplier”, he said. In addition, when looking at the challenges in funding healthcare in Nigeria, the inconvenient truth is that the government cannot fund the infrastructure requirements of the health sector. The bulk of the federal government’s expenditure is spent on recurrent expenditure leaving little for capital expenditure.

“To ensure that adequate domestic resources are allocated to the health sector, dedicated analytic, policy, and advocacy efforts are required”, Dr. Olamide Okulaja, Director of Advocacy and Communications at PharmAccess Foundation. Photo source: PharmAccess Foundation
If Nigeria is to adequately fund its health sector, we need to view healthcare not as an expense, but as a business. According to Dr. Olamide Okulaja, Director of Advocacy and Communications at PharmAccess Foundation, financing is not the only solution to solving Nigeria’s healthcare problems. He said that we would also need to have systems that are in place to absolve financing and continually justify its release. “To ensure that adequate domestic resources are allocated to the health sector, dedicated analytic, policy, and advocacy efforts are required”, Dr. Olamide added. The role of the government in this mix is to ensure that they create the enabling environment for the private sector to support the running of primary health care facilities. They should be regulating and providing governance in healthcare and let the private sector use their expertise and competence to deliver healthcare.

Healthcare needs to be seen as a business and only bankable ideas get funding. With PPPs you cannot do collateral borrowing and so the healthcare provider is borrowing against the future cash flow that will come from the business. This provides reassurance for the financing organisation for the loan will be repaid. We all have an enlightened self-interest, so it is in our best interest to fix healthcare in Nigeria and look for solutions outside of traditional government financing to address the funding challenges in healthcare.

Case study – Toronto Hospital brings healthcare to the Polobubo Community
How do you provide health care for a community left out of the health system for many years? That is the story of Polobubo, in Delta State, one of the most remote hard-to-reach communities in Nigeria. With a population of about 75,000 inhabitants, the community had until recently no access to healthcare due to their extreme isolation and remoteness.  Accessing Polobubo through its closest town Warri, requires a 3hr 45mins boat ride, travelling with a 200-horsepower double engine speed boat, through the Niger Delta creeks, and across the Atlantic Ocean.


“We are breaking boundaries and getting healthcare to areas no one will dare”, Dr. Emeka Eze, Toronto Hospital. Photo source: PharmAccess Foundation
The high maternal and infant death rates would have continued in Polobubo if not for the intervention of the Delta State Health Insurance Scheme delivered through a PPP model consisting of PharmAccess Foundation’s Medical Credit Fund’s Access to Finance framework, the Bank of Industry and Toronto Hospital, in Anambra State. A successful approach, the model had registered 2,639 enrollees who pay an annual premium of N7,000 and attended to 3,990 cases, including caesarean sections, minor surgeries, appendectomies in the Polobobo health facility, within two months of operation. All of these and many more success stories would not have been made possible without a PPP. “We are breaking boundaries and getting healthcare to areas no one will dare”, Dr. Emeka Eze of Toronto Hospital said.
Also Read Health For All: Achieving Universal Healthcare Coverage in Nigeria | Adaku Efuribe

Now what? The Scalability of the PPP model in healthcare
In the 2019 health budget, about ₦50billion has been allocated for capital expenditure. Clearly, this amount is unable to cover the infrastructure gap in the healthcare industry and cater for the health needs of Nigeria’s burgeoning population of almost 200 million people. Can PPPs fill the gap in health funding? The government does not trust the private sector due to fear that they will put profit before performance, however, there appears to be a sea change. For the first time in Nigeria, two state governments are releasing funds to the private sector to revitalise some of their healthcare facilities. This is a testament to the political will in Lagos and Delta State to partner with the private sector.


The PPP model registered 2,639 enrolees who pay an annual premium of N7,000 and attended to 3,990 cases, including caesarean sections, minor surgeries, appendectomies in the Polobobo health facility, within two months of operation. Photo source: PharmAccess Foundation
In 2017, the federal government flagged off its Primary Healthcare Revitalization Programme, announcing its target of revitalising 10,000 PHCs in Nigeria. Recently, the Minister of Health, Prof. Isaac Adewole, however, said that the government has only been able to revitalise 4000 PHCs. Could financing be a major hindrance to achieving the FG’s target? Perhaps this is an opportunity for the private sector? In joining the PPP vehicle, the words of Mr. Olufisayo during the policy dialogue, come to mind “If you want to be a good public-private-partnership candidate, do not come alone. You have a better chance if you collaborate with others. The strength of the pack is the wolf, and the strength of the wolf is the pack”.
 
The first panel at the policy dialogue focused on financing healthcare projects. Photo source: PharmAccess Foundation
The ability to scale up PPPs needs to be driven by government policy, regulation and political will, critical enabling conditions for the successful implementation of PPPs. This was seen with the partnership between the Lagos and Delta State governments and other stakeholders; the public sector commitment was evident. Dr. Olaokun Soyinka mentioned during the policy dialogue that “Government needs to advocate within government”, and so promoting the benefit of PPPs. Evidence of a successful PPP model, as Engr. Chidi Izuwah pointed out, was Garki Hospital, in Abuja, the first ever public-private partnership in the Nigerian health sector.

Under the stewardship of Prof. Chris Bode, the Chief Medical Director at the Lagos University Teaching Hospital, a state of the art Cancer Centre was commissioned in partnership with a consortium that included the Nigeria Sovereign Investment Authority (NSIA) in February 2019.


The second panel at the policy dialogue focused on creating synergy for PPPs to strengthen primary healthcare delivery. Photo source: PharmAccess Foundation
PharmAccess Foundation’s journey in PPPs has shown significant promise and evidence of the organisation’s successful partnerships can be seen in the revitalised primary health centres in Lagos and Delta State. So, opportunities to scale up PPPs this model is encouraging in the absence of more funds being directed at the health sector.  The role of the government is critical and as public funds are increasingly being invested in the private sector, we are slowly pushing ahead in the journey towards Universal Health Coverage.

A detailed report of the policy dialogue will be made available. Please contact info@nigeriahealthwatch.com for further details. If you would like to watch the live coverage of the event and see photo highlights, kindly visit our Facebook page. To view some of the presentations from the event, click here

Health

Kasha Global Inc. secures $1 Million DFC equity investment to grow and scale across East Africa

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Kasha Global Inc. beneficiaries (Source: DFC)

U.S. International Development Finance Corporation (DFC) today announced the disbursement of a $1 million equity investment in Kasha Global Inc., an e-commerce company that provides women’s health and personal care products to customers in Rwanda and Kenya, alongside investments from Finnfund and Swedfund. This investment was made through DFC’s Portfolio for Impact and Innovation (PI2) initiative, which aims to finance early-stage, high-impact solutions to challenges facing developing countries.

“High quality and equitable health services and products are fundamental to the wellbeing, and ultimately the economic potential, of women and girls in the developing world,” said Vice President for DFC’s Office of External Affairs Algene Sajery. “DFC is proud to support Kasha’s innovative business model, which is helping transform the personal care and health system supply chain in East Africa, and provide financing that strengthens economic growth in the region.”

“Kasha is excited to bring DFC on as an investor and as a long term partner,” said Kasha Global Founder & CEO Joanna Bichsel. “With the U.S. Government’s significant ongoing investments in the areas of Global Health and with DFC’s focus on supporting businesses proven to drive both commercial returns as well as social impact, we see strong win-win opportunities as Kasha continues to grow and scale across East Africa and beyond. We have been impressed with the level of support DFC is extending into emerging market businesses and into women-led and women-focused businesses.”

Many women in emerging markets lack access to safe, high-quality, and affordable health and personal care products as well as information surrounding these products. As products are often out of stock or counterfeit, the purchasing experience can be frustrating and disempowering for many women. Further, the stigma surrounding women’s health and personal care products in some cultures can have serious consequences. A UNESCO report estimates that one out of 10 girls in sub-Saharan Africa misses school during her menstrual period, amounting to as much as 20 percent of the school year.

Since 2016, Kasha has helped address women’s lack of access to health and personal care products by delivering a unique, discreet and user-friendly purchasing experience to the customers it serves. Through its e-commerce platform, Kasha has reconfigured the supply chain, delivery channel, and customer experience in order to meet demand. Kasha’s business-to-customer line of business directly sells products to customers in rural and urban locations across East Africa, especially low income communities. Kasha empowers over 400 local women to enter hard to reach communities to provide information and assist customers in purchasing products. The company’s business model is optimized to reach low income communities. Kasha has delivered over 1 million product units to over 130,000 unique customers, of which 63% are low income customers in Rwanda and Kenya.

Despite Kasha’s rapid growth and loyal customer base, fundraising is extremely challenging for start-ups in emerging markets, particularly during the COVID-19 pandemic. By investing $1 million in equity through the PI2 program, DFC aims to help Kasha fill the financing gap, providing the e-commerce company with the capital required to scale its business.

DFC’s investment advances its 2X Women’s Initiative, which has committed more than $4 billion of investment in projects that empower women in developing countries. The Kasha investment also qualifies for the 2X Challenge, an initiative of the G7 countries to support women’s economic empowerment. Kasha was co-founded by two women, 50 percent of Kasha’s senior leadership team are women, 75 percent of board members are women, 64 percent of Kasha’s employees are women, and the company’s products center around care for women and girls. Based on Kasha’s commitment to the 2X Challenge criteria, Kasha, DFC, Finnfund and Swedfund have signed a side letter which highlights Kasha’s 2X accomplishments and sets an example for other companies that seek to improve their businesses using the 2X Challenge criteria.

By focusing on innovative care delivery models and supply chain innovations, DFC’s financing also advances the agency’s Health and Prosperity Initiative, helping respond to COVID-19 and other health-related issues in Rwanda and Kenya.

Swedfund is Sweden’s development finance institution. Finnfund is the Finnish development finance institution.

DFC

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Play Zuri Health launches its first mHealth App to help provide affordable and accessible healthcare solutions

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Play Zuri Health Limited Mobile App (Source: Zuri Health)

Play Zuri Health Limited, a branch of the Play Communications Limited announced the launch of their first mobile app, Zuri Health; that can be downloaded from the Google Play Store, Apple Store as well as the Zuri Health website.

Zuri Health’s mission is to provide certified, affordable and accessible healthcare solutions via mobile with dedicated apps, wap and SMS services based on availability, location and specialization of the medical providers.

Users will have access to a myriad of professionals and services from across their home counties. They are able to book appointments instantly with any medical professional or hospital within their geographic regions, book laboratory tests, chat with the practitioners via both message and video as an added feature and request for home visits by the Licensed and Certified Medical Practitioners.

Under Pharmacy, users can get their prescription and over the counter medication online and have it delivered to their doorstep.

The SMS service functionality of Zuri Health has been designed to reach a wide range of individuals or users who may not have access to WAP or internet enabled devices.

The app’s code was written with the daily challenges patients face in the journey of seeking affordable and accessible healthcare solutions. We solve the problem of expensive and inconvenient hospital trips for small or minor diagnosis and prescriptions, long waiting times and queues during doctors’ visits and appointments scheduling and booking which can be tasking.

Through our mobile app, we also help doctors to tap into a wider market of on-demand patients and earn extra money while saving lives.

Play Zuri Health Limited co-Founders, Arthur Ikechukwu Anoke and Daisy Isiaho (Source: Zuri Health)

“Zuri Health App is very personal to me. Millions of people in Africa do not have access to quality medical care. At Zuri Health we have taken time to develop a product that will fill that gap, giving doctors a wider and easier platform to reach patients who need them. With Zuri Health the underserved populace can now access affordable and sustainable healthcare.” Arthur Ikechukwu Anoke- C.E.O and Co- Founder Zuri Health.

Daisy Isiaho Project Manager and Co-founder in an interview said, “In my view, there is an urgent need to drive more meaningful conversations in relation to frameworks around Telemedicine because in Africa very few countries have these yet its fundamental if we should achieve the Sustainable Development Goals.”

Since the beta launch in November 2020 the company’s predicted three year growth plan is to have more than 20,000 registered doctors listed, 250,000 premium users and at least 1,000,000 mobile downloads.

Visit Zuri Health

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Live A Full Life With Sickle Cell Disease

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Kunle Tometi a Pharmacist, Entrepreneur and Public Health Advocate.

The World Sickle Cell Day is a United Nation’s recognized day to raise awareness about sickle cell disease (SCD) at a national and international level. On 22nd December 2008, the UN General Assembly adopted a resolution that recognizes sickle cell disease as a public health issue and “one of the world’s foremost genetic diseases.” The resolution calls for UN member states to raise awareness about sickle cell on June 19th of each year.

In this article, I would be creating awareness on sickle cell disease, the causes, symptoms, treatment and prevention.

What is sickle cell disease (SCD)

Sickle cell anemia (sickle cell disease) is a disorder of the blood caused by inherited abnormal hemoglobin (the oxygen-carrying protein within the red blood cells). The abnormal hemoglobin causes distorted (sickled) red blood cells.

Occurrence

SCD is more common in certain ethnic groups, including:

  • People of African descent,
  • Including African-Americans (among whom 1 in 12 carries a sickle cell gene)
  • Hispanic-Americans from Central and South America
  • People of Middle Eastern, Asian, Indian, and Mediterranean descent
  • Approximately 2000 infants are born annually with the disease
  • SCD affects approximately 200,000 Americans annually
  • 1 in 365 African Americans
  • 1 in 13 African Americans have the traits (carrying only 1 of the gene, S)

(CDC August 2017, Mayo Clinic)

Economics of SCD

10 years ago; Medical expenditure for children with SCD averaged $12,000 yearly for those with Medicaid and $15,000 yearly for those with commercial insurance.

There were also 113,000 hospitalizations costing over $500,000 paid by Medicare and Medicaid of which 75% of the visits were in adults and each with at least 3 Emergency Room visits per year. Children with SCD miss a minimum of 18 days per school year

Total healthcare costs nowadays for SCD is estimated at $2billion per year.

According to (David A.N et al 2018), ‘In Nigeria, the prevalence of SCD is 20–30/1000 live births. The burden of the disease has reached a level where it contributes 9–16% to under-five mortality in many West African countries. Hemoglobinopathies alone represent a health burden comparable to that of communicable and other major diseases’

Causes of SCD

Healthy red blood cells are round, and they move freely through small blood vessels to carry oxygen to all parts of the body. In SCD, the red blood cells become hard and sticky and look like a C-shaped called a “sickle” and they are not able to carry enough oxygen. When they travel through small blood vessels, they get stuck and clog the blood flow.

The sites most often affected by clogging or stacking of sickle cells are found in the lungs, liver, muscle, bone, spleen, eyes, and kidneys and other parts and tissues of the body: explains why patients complain of a lot of pain in these areas as the symptom of the disease.

Patients also have immunity suppression which leads to infections by bacteria, and viruses.

Symptoms of SCD includes;

  • Excessive fatigue, irritability from anemia
  • Jaundice (yellowing of eyes and skin), may also include retina damage
  • Swelling and pain in hands, and feet, Pain in chest, back arms and legs, also damage of hip
  • Frequent infections,
  • Pain and problems in the spleen, (Nausea, vomiting, diarrhea)
  • Delayed growth
  • Stroke (20–30% of children stroke, 23% in African Americans)
  • Genitalia (priapism, a constant erection, in which severe episodes may lead to impotency)

Treatment of Sickle Cell Anemia

Treatment of SCD pain or crisis is done in the following manner:

Rehydration: with IV fluids, helps Red blood cells return to normal shape

Also Read: The ELMA Group of Foundations Commits ZAR 2 Billion to COVID-19 Response in Africa

Drugs:

  • Antibiotics: used to treat underlying infections. In some cases antibiotic prophylaxis, penicillins are recommended.
  • Pain medications to treat acute pain
  • Hydroxyurea: helps increase production of red blood cells

Immunization: Pneumococcal and Meningococcal vaccines have drastically reduced the rate of infections in SCD

Blood transfusion: improves oxygen and nutrients needed

Supplemental oxygen by mask makes breathing easier and improves oxygen levels in the blood

Bone marrow transplant: for severe complications and matching donors.

Prevention

  • Genetic counselling and testing (better before marriage and at pregnancy) can help prevent the likelihood of passing gene to your child
  • Preventing infections can be achieved by practising simple hand washing techniques at every opportunity. Hand sanitiser gels and wipes are also available and affordable
  • Immunisation is very important and one must assure shots and records are current to cut down on the rate of common infections.
  • Re-hydration with fluids at all times is essential.
  • Avoid staying in places with low concentration of oxygen, e.g. unpressurised air planes, or high altitudes

For more information about SCD, please speak to your Pharmacist or Doctor.

Article by Kunle Tometi a Pharmacist, Entrepreneur and Public Health Advocate.

Ref:

  • https://en.wikipedia.org/wiki/Sickle_cell_disease.
  • Mayo clinic https://www.gstatic.com/healthricherkp/pdf/sickle-cell-anemia.pdf
  • CDC https://www.cdc.gov/ncbddd/sicklecell/data.html
  • Sickle cell Disease: Public health agenda & Social, Economic and Health implications by CDR Althea M Grant, PhD September 2012
  • www.score_international.org/resources/conference_presentations
  • Overview of the management & prognosis of sickle cell disease, Joseph Palermo, D.O.
  • Economic impact of sickle cell Hospitalization. R Singh, Ryan Jordan and Charin Hanlon
  • www.bloodjournal.org/content/124/21/5971
  • Prevalence and impact of sickle cell trait on the clinical and laboratory parameters of HIV infected children in Lagos, Nigeria

Prevalence and impact of sickle cell trait on the clinical and laboratory parameters of HIV infected children in Lagos, Nigeria.

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