Healthcare in Africa : are Public Private Partnerships and e-Health sound options to advance public health with limited public funds ?

Covid-19 has pushed all countries to assess and benchmark their health infrastructures. From 0,1 hospital beds per 1000 people in Mali to 13 in Japan, the gaps are massive. There is now greater alignment than ever around the globe on the need for adequate capacities to deal with health challenges. A recent study has estimated the necessity for Africa to build as many as 15,000 new modern hospitals (4 million beds).

Concurrently, with an African continent having entered recession for the first time in 25 years, and now above 600Bn$ debt in Sub-saharan Africa, fiscal space often appears extremely limited.

So calling on the most effective and efficient approaches is crucial for many African countries. Two directions are gaining increased traction: Public Private Partnership (PPPs) and digital Health. But what are conditions for these projects to succeed?

PPPs: start small (even if you think big)

Those who have participated in Health PPPs and reflect on their experience will give you a nuanced picture. The spectrum goes from palpable failure to debatable success. In the cases were PPPs did not meet expectations, at least 3 mistakes were made:

PPPs considered more as an end (delivering a major health object) than as a means (making a decisive step for the population’s public health);
acting on a proposed opportunity, potentially an unsolicited offer, rather than sufficiently scrutinizing the current and emerging health needs, and their local specificities;
disregarding the real context of the country in terms of competencies (medical, managerial…), legal frameworks and financing options.

In any case, a solid value-for-money analysis should support decision-making and arbitrages between different options.

Besides, Health PPPs are not a uniform reality: since their inception in the 1990s, they have taken a variety of shapes around the world. These can be broadly categorized in 3 groups:

Infrastructure (1990 onwards): typically the construction of an hospital, and possibly the provision of ancillary services (catering, laundry…). Within this non-medical envelope, the medical staff and operations remains public and are not included in the partnership (case of Bareeq for Alexandria Hospitals in Egypt);
Integrated (2000 onwards): a “turnkey” approach where the private partners provide for the financing, construction, operations of the health unit, including its medical components (doctors and nurses recruited and paid by the Project Company – case of Queen Mamohato Memorial Hospital in Lesotho);
Focused on a given service (2005 onwards): a narrow scope partnership around a specific health operation, eg the roll-out of MRI centers across the country (potentially hosted in public facilities – case of General Electric diagnostic imaging equipment in Kenya).

Each of these categories has its own dynamics of risk sharing, complexity and key success factors. Experience suggests that “integrated PPPs” are the most complex and require high maturity to be managed effectively; “infrastructure PPPs” are also large projects, regularly criticized for being oversized or not evolutive enough; “focused service PPPs” have encountered greater success recently, in particular those including a training and skills development objective for the private partner.

It is essential to think big (developing scenarios for public health needs in the coming 30 years) and develop ambitious roadmaps to improve the population’s physical and mental health in the long run, with adequate facilities and equipment. Yet, it is equally important to engage in a learning curve that starts with small steps, typically focusing first on a dedicated health service that is insufficient in the country (dialysis centers, radiology units…). This is a safe way for any country, and therefore for African countries as well, to progressively build a system and a set of experience on which a PPP approach can be scaled-up, potentially more and more ambitious as learning accumulates.

Digital health: focus on key enablers

The promises of digital health are immense, from a better leverage of social workers (eg on maternity programs in rural areas with solutions like CommCare in Nigeria, Sierra Leone, Zambia...) to disease management, universal access to teleconsultation (eg Uganda with Babylon), efficient management of health facilities…

Yet, particularly in Sub-Saharan Africa, the environment, though rapidly improving on certain aspects is still far from being conducive to taking e-health at scale. With less than 50% of the population with access to electricity and even less with access to (high-speed) Internet, the foundations are still under construction. Other barriers need to be overcome, from shared phone use and low-quality devices, or to strong societal divides (urban-rural, gender, local languages).

In this context, strong leadership and governance are required to create an enabling environment for e-health, bringing together the strategies of a series of Ministries and Administrations, in particular Telecom, Health, Education and Finance, each having a key role to play, for instance:

Telecom: beyond internet access and mobile development, privacy frameworks are essential to build trust in e-health;
Health: regulatory frameworks governing access to care need to be expanded and integrate new use cases and types of players (eg platforms);
Education: scaling-up e-health requires to ensure a sufficient base of doctors and nurses will be able to provide care to a greater part of the population; also, new profiles and types of competencies are essential to fully benefit from digital care: human resources required to design, deploy, manage and/or use these technologies in support of healthcare need to be properly trained : a diverse workforce of Digital Health Workers needs to be engaged holistically in order to develop, operate and support the national eHealth environment;
Finance: investments in public infrastructures and initiatives need to be properly funded with an optimal balance of public and private participation.

Without these key enablers, e-health might not reach scale, making it impossible to progress decisively towards the shared Sustainable Development Goals (SDG #3 on health, SDG #10 on inequalities). Of course, while the enabling conditions are being developed, a “test and learn” approach, particularly suited for e-health, needs to be adopted immediately to grasp any low hanging fruit available.

So, back to our initial question: are Public Private Partnerships and e-Health sound options to advance public health with limited public funds in Africa?

Digital health strategies as well as private public partnerships can bring high impact answers if managed in a patient-centric, value-driven way. In the coming quarters, it will be particularly interesting to see how the Chinese “Belt & Road initiative”, that seems to increasingly target health and tech projects, will unfold in Africa on these matters. We welcome your thoughts on whether this can open a new era for public health across the continent!

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