Recent years have seen increased governmental commitment for universal health coverage (UHC) through policy and financing reforms, with many African governments having (marginally) increased their health spending as a percentage of overall spending. This increase, however, remains inadequate and in most countries falls far below the 15 per cent target agreed at the Abuja Declaration in 2001. Poor management and leakage further diminishes resources for health, thus increasing out of pocket costs and creating an inequitable system wherein only the rich can afford to pay for care.

With public health services often inaccessible, understaffed or lacking sufficient quality, many people turn to the private sector to access health care, often paying out of pocket. In sub-Saharan Africa, about 50 per cent of health care is delivered through the private sector, with private facilities being the first call for high and low-income families. It is now clear that UHC will only be possible by strengthening and improving both public and private health sectors, and through public-private partnerships.

The term private sector in this context, is broad and should not be misconstrued to mean, expensive and profit-driven. “Private sector” includes all health providers not owned or directly controlled by the government. This is diverse and includes profit and not-for-profit, formal and informal, domestic and international. Across Africa, healthcare products and services are delivered through a range of private providers such as maternal homes,
pharmacy shops, dispensaries and primary health centers. This also includes social enterprises, NGOs and faith-based institutions such as those taking part in the Christian Social Services Commission (CSSC) in Tanzania
6or the Christian Health Association of Ghana (CHAG). Despite their crucial role, private health sectors in Africa remain weakly regulated, and highly fragmented. Clinics and small healthcare businesses are seen as ‘risky
investments’ by local banks and therefore struggle to access capital needed to improve their services and grow their businesses.

As part of the PharmAccess Group, the Medical Credit Fund (MCF)  was set up in 2009 to help address these issues, driving more financing and support into the health sector. MCF is the only fund dedicated to financing health SMEs (small and medium enterprises) in Africa, enabling them to access the capital and technical assistance needed to improve quality of care and expand their businesses. Through a blended finance structure, MCF provides flexible, affordable loans to health SMEs and quality improvement support through the internationally accredited quality improvement program, SafeCare.

Over 1,800 health SMEs have used MCF across Africa, mainly in Kenya, Tanzania, Nigeria, Ghana and Uganda. So far, US$ 140 million has been disbursed in loans to healthcare providers, ranging from primary health centers to maternity homes, dispensaries and smaller hospitals, and suppliers to the health sector. The high loan repayment rate of 94 per cent (97 per cent before COVID-19) proves that investing in quality healthcare is not risky, and shows that the African health sector is bankable. Thus, stimulating further health sector investments and growth, while supporting clinics to improve the quality of care they provide for their patients.

The widespread mobile and digital adoption in African countries now brings opportunities to leapfrog healthcare financing and delivery. This has brought a growing local demand for digital lending tools, which MCF answered in 2017 with the launch of ‘Cash Advance’. In Kenya, the advanced mobile money ecosystem (M-Pesa) offered a gateway to roll-out this digital loan product with key implementing partners Safaricom (telco), CarePay (technology company), and in consultation with healthcare providers. Since then, MCF’s digital lending has grown in popularity, with around US$ 50 million dispersed so far.

By integrating into the thriving mobile money ecosystem, Cash Advance allows small and remote healthcare providers to easily access working capital loans using their mobile phone. It has grown in popularity due to its flexible and convenient nature, and short processing time (less than 24 hours). Repayment is based on actual mobile money revenues and no collateral is required. Cash Advance was developed in collaboration with users, and 70 per cent of users are repeat customers.

Digital lending through Cash Advance has proven crucial during the pandemic, with COVID-19 increasing mobile money use and reducing banks’ appetite for SME lending. Small and remote clinics risked closure and could not access banks loans to cover cash flow gaps or buy personal protective equipment (PPEs). Cash Advance offered the solution due to its convenient and flexible nature, disbursing US$ 22 million in 2020 alone.

Beyond the pandemic, MCF and partners will continue to scale digital lending to the health sector. With demand soaring in Africa, digital tools like Cash Advance will be integrated into countries’ broader mobile and digital health ecosystems, supporting sustainable social and economic development.

For sustainability, African governments must ensure that health services are accessible and of good quality, and finance basic health insurance for all, especially for those who cannot afford it. Yet these efforts need to be supplemented and complemented by a well-monitored and incentivised private sector. In this regard, MCF, together with SafeCare and partners are playing a key role in the journey towards UHC, with mobile tools like Cash Advance helping to accelerate progress. The innovation recently won the Finance for the Future Awards, recognizing its sustainable contribution and impact towards health system strengthening.

At the recent launch  of MCF2 in July, 2021, the Managing Director of MCF, Arjan Poels, said:

During the same event, his Excellency Maarten Brouwer, Ambassador, Embassy of the Kingdom of the Netherlands in Kenya said:

1. https://gh.bmj.com/content/4/Suppl_9/e001193

2. https://www.un.org/africarenewal/magazine/october-2020/public-financing-health-africa…

3. https://ghrp.biomedcentral.com/articles/10.1186/s41256-021-00190-7

4. https://www.unido.org/sites/default/files/2016-01/IFC_HealthinAfrica_Final_0.pdf

5. https://cdn.who.int/media/docs/default-source/health-system-governance/private-health-sector-an-operational…

6. https://cssc.or.tz/

7. https://chag.org.gh/

8. https://www.medicalcreditfund.org/

9. https://www.safe-care.org/

10. https://youtu.be/PztqoohWYvE

11. https://www.informaconnect.com.sg/insight/covid-19-pandemic-intensified-conversations…

12.https://www3.weforum.org/docs/WEF_Seven_ways_the_private_sector_can_contribute_to_universal_health.pdf

13. https://www.weforum.org/agenda/2019/04/5-ways-private-sector-can-give-african-healthcare-a-shot-in-the-arm/

14. https://www.medicalcreditfund.org/update/medical-credit-fund-mcf-this-years-winner-for-moving-financial…

15. https://www.medicalcreditfund.org/update/healthcare-businesses-in-africa-to-benefitfrom…

For further information, please contact Liam Aru Levy Philipp, Advocacy Officer, PharmAccess Group [email protected]

In 2012, South Africa launched the National Development Plan 2030 (NDP) that aims for the country to eliminate poverty and reduce inequality. Similar to the Sustainable Development Goals, the NDP set a target to achieve Universal Health Coverage (UHC) by 2030. Through the national pooling of risk and funds, the National Health Insurance (NHI) scheme is aimed at provision of quality health services for all South Africans through application of the principles of social solidarity, cross-subsidisation and equity.

– Dr ZL Mkhize. Former Minister of Health

In line with the transformation of the health care sector required for implementation of NHI, the National Digital Health Strategy for South Africa (2019 – 2024) sets out a vision of ‘Better health for all South Africans enabled by person-centred digital health”. The strategy recognises digital health’s potential to be a significant driver of the required health systems transformation and reengineering.

The success of NHI in South Africa was identified to be underpinned on the functioning of the public health system. Thus, to strengthen the health system, the National Department of Health aims to establish an integrated digital health ecosystem of people, processes and technology for efficient service delivery and effective patient care necessary for achieving UHC.

The digital health strategy prioritised the scaling up of high impact mHealth initiatives for community-based interventions. One of those initiatives is the MomConnect programme which was developed by the National Department of Health through a coalition of public and private partners.

MomConnect is a mobile phone-based service that is integrated into maternal and child health services with the objective of sending targeted health promotion messages to improve maternal and neonatal health. Pregnant women subscribe to the service via a USSD number. They then receive stage-based messages on antenatal care, labour, newborn care, breastfeeding and immunisation.

The service strengthens the maternal and child health programme by being a mechanism for a national universal pregnancy registry that collects information on pregnancy statuses and gestational age. It promotes utilisation of available antenatal and post-natal services during and after pregnancy. Its help desk feature allows pregnant women to send any complaints or compliments via SMS, thus becoming an interactive way to give feedback on the service they received. Ultimately, MomConnect is generating strategic information on how maternal and child health delivery could be improved in the country.

MomConnect has proven to be impactful due to its easy-to-use features and high accessibility as a free service providing useful information in all 11 official languages of South Africa. More than 2.5 million mothers have registered with MomConnect since its launch in 2014 with the service now expanding to using WhatsApp as a medium.

Another significant mHealth application scaled up to strengthen the health system is the Stock Visibility System (SVS). SVS is a mobile, phone-based stock monitoring and evaluation system. designed to increase access to accurate, timeous medicine availability information from health facilities. It provides a mechanism with which stock levels, expiry dates, stock received and projected stock requirements can be recorded, analysed and reported to the health managers. South Africa’s Department of Health partnered with Vodacom Foundation for the roll out of SVS in provinces across the country.

South Africa recognised that several digital health building blocks need to be put in place in preparation for the NHI implementation. The department of health aims to create an integrated and enhanced national health information repository and data (NHIRD) system. This is coupled with a HPRS project aimed at creating a patient and service provider registration system and the implementation of a national electronic health record (EHR) system to register and track patients who visit different health care providers. The NHIRD is regarded as crucial as it will provide data and analytics needed by the National Health Insurance fund.

As another digital health foundation piece, the country developed a National Health Normative Standards framework for Interoperability in eHealth in South Africa. This is a framework used to conduct compliance assessments for patient information systems and hospital information systems towards digital health interoperability in South Africa.

To strengthen the enabling environment for digital health, laws such as the Protection of Personal Information (PoPI) Act, 2013 were introduced to help mature the regulatory environment. The digital health strategy also aims to establish a robust physical and network infrastructure and broadband connectivity for priority digital health applications and services. Regarding human resource capacity, the country aims to establish a digital health workforce plan that identifies and develops critical technical skills required to drive implementation of the digital health strategy in partnership with diverse learning institutions. South African-based universities have started developing digital health short courses, and supervising Masters and PhD students exploring digital health topics.

– Dr PA Motsoaledi, former Minister of Health.

More investments will be required to consolidate and expand the current efforts to realise the benefits of digital health in improving service delivery and patient outcomes in support of NHI. In this endeavour, the Minister of Health is supported by a Ministerial Advisory Committee (MAC) on eHealth. The committee provides guidance on the path that South Africa should follow to benefit from digital health advancements.

● Health systems require several mechanisms to improve their efficiency and control their costs for a country’s ability to achieve UHC. Health system strengthening through the use of digital health interventions is a way to address challenges and remove bottlenecks as part of the transformation needed for achieving UHC.

● Effective collaboration between public and private sector stakeholders are needed to build and scale up cost- effective digital health solutions.

● Digital health foundation pieces required for UHC through NHI include a national electronic health record built on a substantial architecture and framework for digital health interoperability.

References:

1. National Development Plan 2030. Our Future-make it work; National Planning Commission, Department of the Presidency of the Republic of South Africa; 2012.

2. Strategic plan 2020/21-2024/25; National Department of Health Republic of South Africa; 2020 (Quote)

3. National Digital Health Strategy for South Africa 2019 – 2024; National Department of Health Republic of South Africa; 2019 (Quote 2)

4. https://www.health.gov.za/momconnect/ [accessed 15 October 2021]

5. https://www.himss.org/resources/impact-momconnect-program-south-africa-narrative-review [accessed 15 October 2021]

6. https://medium.com/mobileforgood/praekelt-org-pilots-whatsapp-for-social-impact-19a336f5b04e [accessed 15 October 2021] (for the image)

7. Katurura MC, Cilliers L. Electronic health record system in the public health care sector of South Africa: A systematic literature review. Afr J Prim Health Care Fam Med. 2018;10(1):e1-e8. Published 2018 Nov 20. doi:10.4102/phcfm.v10i1.1746

8. https://vodacomfoundationsa.co.za/health/ accessed 15 October 2021]

On 23 September 2018, India launched the world’s largest universal health coverage (UHC) scheme named Ayushman Bharat Pradhan Mantri- Jan Arogya Yojana (AB-PMJAY), which intended to cover 500 million Indians in the bottom 40 per cent of the Indian population. The scheme provides cashless cover of up to INR 500,000 to each family for secondary and tertiary care hospitalisations. Safeguarding that primary health care is not left out, the scheme also proposes establishing 150,000 wellness clinics by transforming existing sub-centers and primary health centres, the country’s two lowest level health facilities. Other than providing curative services, the wellness clinics will also emphasise disease prevention and health promotion. Thus, AB-PMJAY takes a holistic view of securing families from diseases and subsequent financial catastrophes while ensuring a sustainable UHC scheme.

Having 28 states and 8 union territories, Indian health care is devolved, and health is a state subject. Many states and union territories had their health protection schemes.Ayushman Bharat strives to and has been largely successful in unifying most schemes under one umbrella, thereby promoting a one-nation-one-UHC model.

There were many precursors to AB-PMJAY, such as Employees State Insurance, Rashtriya Suraksha Bima Yojana, Central Government Health Scheme, and a few others. AB-PMJAY is different from its precursors on several measures, the most important of them being the robust digital architecture that complements the scheme. An extensive provider-linked information system has been created to make payments. Also, the technology platform leverages artificial intelligence and machine learning to prevent abuse and control fraudulent transactions.

India has a long history of digital health initiatives, including telemedicine and e-pharmacies, though they have been sporadic and uneven. The National Health Policy 2017 emphasises citizen centricity, quality of care, better access, UHC and inclusiveness as some of the core principles of Indian health care. Technology is a critical component that can help realise these principles; however, an interoperable enterprise-level federated digital architecture was necessary to bridge the gaps and make the system even, especially considering the diversity and complexities of the Indian health system.

The above needs led to the development of the National Digital Health Blueprint (NDHB), a layered framework with a set of core principles surrounded by other layers relating to digital health infrastructure, data hubs, building blocks, standards, and regulations. The blueprint also included an institutional framework and a high-level action plan for its implementation. The blueprint has 35 building blocks, some of which consists of the following critical capabilities.

● Identification – Every citizen will have a unique health ID and access to a health locker enabling access to their health records from anywhere, thereby ensuring continuum of care. The blueprint also has a health care provider registry, a comprehensive collection of all health care professionals and facilities in the country. The beneficiaries and providers can self-enroll to create their IDs.

● Citizen Centricity – The blueprint identifies a set of building blocks that emphasises the gold standard for maintaining health records’ security, confidentiality, and privacy.

● Service Delivery – The blueprint combines web and mobile applications for delivering services on a mobile-first approach. Such applications include telemedicine and e-pharmacy.

● Interoperability – The blueprint promotes the creation of a Health Information Exchange and National Health Informatics Standards to enable interoperability.

Built on the guiding principles of “Security and Privacy by Design” and “Think Big, Start Small, Scale Fast,” the COVID-19 pandemic necessitated rapid adoption of many digital health initiatives that were part of the blueprint. The National Telemedicine Practice guidelines were released on 25 March 2020, and subsequently, eSanjeevani, the national teleconsultation service, was fast-tracked and commissioned in April 2020. eSanjeevani is now among the largest telemedicine networks in the world, and more than 14 million online consultations were conducted by October 2021.

The blueprint also allows integration of all the stakeholders, a sandbox, and an API interface to integrate other private and public digital health applications. The blueprint transpired into the National Digital Health Mission (NDHM), which was piloted in 6 union territories from 15 August 2020, before it was rechristened as Ayushman Bharat Digital Mission (ABDM) and dedicated to the nation on September 27, 2021.

ABDM has been instituted with a vision to create a seamless online platform “through the provision of a wide range of data, information and infrastructure services, duly leveraging open, interoperable, standards-based digital systems” while ensuring the security, confidentiality, and privacy of health-related personal information.

By October 2021, around 168 million beneficiaries were enrolled, and AB-PMJAY had supported over 22.7 million hospital admissions. The programme achieved the milestone of 2 million hospital admissions in August 2021, and official reports indicated that the scheme had provided treatments worth more than INR 250 billion. The programme’s impact can be gauged by the fact that out-of-pocket health expenses account for nearly 63 per cent of the total health expenditure (World Bank, 2018) in India. It is also critical to note that the above volume of services was executed seamlessly through the robust information technology backbone, including the AB-PMJAY One Transaction Management System (TMS) that integrates the entire process from admission, discharges, and onwards till financial settlement.

Being the largest UHC and digital health programmes globally, AB-PMJAY and ABDM foster significant learnings for the rest of the world, especially for countries with devolved health systems. Some of such learnings include-

● A comprehensive blueprint in line with the health system’s vision is quintessential for success. India has demonstrated that with a proper vision and blueprint, a lot could be achieved in a short span.

● Including primary health care – It is critical that UHC includes health promotion, disease prevention, and primary health care to ensure that people’s health care needs are met. AB-PMJAY demonstrates that a scheme favoring hospitalisation alone may not be an appropriate product for LMICs.

● Digital backbone – Digital programmes for rapid beneficiary enrollment, provider management, and delivering quality services to those deprived should be designed complementing the UHC scheme.

● Leadership – Political leadership from the top-most authority along with a multi-pronged approach is essential for rapid success.

● Organisational and operational synergy – Having UHC and digital health under the same umbrella organisation could foster synergy and rapid growth, like the case of the National Health Authority in India.

Kenya’s pursuit of Universal Health Coverage (UHC) focuses on investing in primary health care, in line with the Astana Declaration on Primary Health Care of 2018. Achievement of UHC in the country is challenged by unequal access to health care services as a result of an inequitable distribution of facilities

Although the number of health care facilities in Kenya has increased, many people still have to travel long distances to see a health worker. On average, people live 9.5km from a health facility. This distance needs to be reduced in order for Kenya to realise its UHC aspirations.

Increasing access to health facilities conventionally calls for significant financial investment as building health facilities comes at a cost. However, a private sector entity in the country is pioneering a low-cost model that leverages digital health to increase access to primary health care.

Access Afya provides primary health care through an integrated network of micro-clinics and mobile health programmes. Its asset-light clinics located within informal communities offer a variety of services including consultations, lab testing, chronic condition management, immunisations, family planning, maternal and child health, first aid and emergency care

The clinics are run by clinical officers, not doctors. Clinical officers are guided in their work through the use of digital clinical decision support tools that give prompts on the right questions to ask or laboratory tests to order. If further assistance is needed, the connection to a remote doctor is made via telemedicine. The clinical officers also access continuous health education via an e-learning platform.

The clinics deploy mobile outreach teams into the community that conduct screening for non-communicable diseases via a mobile phone application. The application displays a risk score that informs community health workers on the need to refer a patient to a clinic for treatment. This hub and spoke model allows the clinic to expand its penetration into the surrounding community.

Access Afya also operates pharmacies with integrated telemedicine and rapid test services making pharmacies sites of first entry into the health system. In between follow-up visits and medication refills, SMS texts are sent to patients providing health education and medication reminders. To enhance operational efficiency, the network of clinics runs on a digital health information system that collects patient demographic, medical history, treatment, purchasing and outcomes data.

Realising that most of their clients are not covered by health insurance, Access Afya partnered with a local finance company to provide a range of health financing options including insurance, health micro-loans, savings and memberships. Patients can take up a micro-loan of up to $5 that is repaid via mobile money.

To expand its reach, Access Afya acquired Merck’s CURAFA franchise of clinics. Launched in 2018, CURAFA had a similar model of integrated point of care health facilities that combined pharmacies, primary health clinics, digital health devices, financing solutions and telemedicine to improve health access in underserved communities. The purchase increased Access Afya’s network of clinics to 15 sites across four counties in Kenya, where they have
served over 240,000 patients.

As part of its digital health strategy, the Kenyan government sought to implement an eHealth systems registration and audit framework for creation of a database of certified and licensed eHealth systems. Access Afya became one of the first licensed digital health companies.

Access Afya aligns with the government’s strategy to use digital health technologies to enhance equitable access to healthcare working with the private sector to promote the use of telemedicine to increase reach to the underserved counties in Kenya.