Capacity building is key to expanding African health systems, says Barry Francis
By World Healthcare Journal-
For Africa’s healthcare to grow, it’s vital to build capacity and reduce the proportion of externally funded healthcare, says Barry Francis Healthcare UK infrastructure specialist.
Africa, of course, is not a country or single economy. Talking as if it were can lead to oversimplification and faulty analysis. The gross domestic product per capita (PPP) in Botswana is about US $17,000, (more than in Serbia), in Kenya it is about $3,200, Egypt’s is around$11,000 and in Burundi it is about $740. In the UK it is about $45,000. But, while we see huge differences, there are common trends as countries industrialise, urbanise and make the long journey toward universal health coverage on a continent that is forecast to have a population of 2.5bn in 2050. The EU 28 has a population of slightly more than 0.5bn at the moment.
From a narrow UK perspective, this presents opportunity to do good. It also presents trade and broader commercial opportunities which can align with, and support, altruistic and economic objectives. From the perspective of the citizen of an African country we see the possibility of healthier and longer life as the compound annual growth rate of healthcare expenditure increases at around 6% across the continent. The latest statistics for UK are about 1%.
Many of the proposals for healthcare projects I Have examined have been addressed largely from the infrastructure perspective. They have included proposals for tertiary and secondary care hospitals, clinics and diagnostic centres. Some have focused on the relatively wealthy and others on providing healthcare to the very poor. Finance sources have been mixed: international financial institutions, commercial banks, charities and international aid. Funding might be from public funds, insurance or, the often financially ruinous, self- pay.
As the demand for healthcare and, I hope, the ability to fund that care increases significantly, it is desirable, and practically necessary, to reduce the proportion of externally funded healthcare provided. The finance may come from different sources but the costs will have to be met, and the potential economic benefit received, internally in the longer term. So, aid cannot do the job by itself. It follows that aid should be directed to where it can do most good and to where private finance may fear to venture. Much of this should be in supporting governments in creating, or causing the creation of, the delivery vehicles to secure improved healthcare infrastructure and the systems within which it operates.
Effective healthcare delivery: capacity building
Whether the necessary delivery vehicles are privately or publicly owned, or both, must be a matter of the countries concerned. That said, the services demanded are complex, and it is essential that, through regulation and effective management, delivery must be properly understood, and monitored.
To take a relatively simple example, a country might be seeking to improve and expand its diagnostic clinics. It would not get best value for money simply by getting some clinics built handsome kit installed. To get best value, the equipment must be used in the most efficient way by trained personnel. It should be regularly maintained and updated. So, clinicians and technicians must be trained. The diagnostics service must fit into the broader health economy. And to secure these needs, the contracts to deliver them must be procured and then managed by people who have been trained in these skills. This is not just a question of hiring a few people. In his illuminating book’ Human, Solving The Global Workforce Crisis in Healthcare’, Mark Britnell observes that “in Africa, 25% of the world's disease burden confronts just 4% of its healthcare workforce” in a world which WHO estimates will be short of 18m health workers by 2030.
Meeting the challenges
Some shortfalls might be addressed by ‘leapfrog technology, such as we are seeing in banking, but in order to meet these and much bigger challenges it will be necessary to harness a wide range of skills and to attract finance from a range of sources
Since infrastructure in healthcare tends to be expensive, and to get more expensive as it becomes more ambitious in the good it tries to do, external capital will need to be attracted and much of that will need to be private. Private capital looks for repayment and relative stability. Some of that can be provided by export credit agencies, such as UK Export Finance, providing guarantees for project borrowings. That type of support reduces the cost of risk; it does not replace the need for a well-structured transaction in a realistically structured healthcare economy.
And so again, we come to the need for aid to be directed at capacity building and support for countries building systems to procure and manage healthcare delivery. That means training clinicians, technicians and managers in optimising delivery through resources which will always be not quite enough to get the job done. In the meantime, those providing services and goods from outside the host country will need support in negotiating new approaches in economics and political and business cultures with which they may be unfamiliar. It seems to me that governments and multilateral development banks and other international institutions have vital roles to play in bringing together the actors in new partnering arrangements to meet hugely ambitious and highly worthwhile social, economic and political objectives.
Barry Francis is the Infrastructure Specialist for Healthcare UK in the Department of International Trade. All views expressed are his own opinions.
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