The Cure: Revolutionizing the Business of Healthcare in Africa
The Cure is a deep-dive podcast exploring what it takes to revolutionize the business of healthcare in Africa. Hosted by Temitope Coker, each episode features candid conversations with the people shaping the continent’s health systems, including visionary founders, investors, researchers, policymakers, and reformers.
We go beyond surface-level insights to unpack the real-world challenges, innovations, and investment strategies transforming care delivery across Africa. At the same time, we aim to infuse hope into the narrative by spotlighting the momentum and progress already unfolding across the continent.
From financing and infrastructure to research, technology, and policy, The Cure is the place for serious thinkers and doers who care about the future of African health.
The show is powered by TC Health, a platform providing healthcare and pharmaceutical insights in Sub-Saharan Africa.
The Cure: Revolutionizing the Business of Healthcare in Africa
Private Sector, Public Impact: Building the Partnerships That Make Care Work - Part 2 | A Conversation with Njide Ndili
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The private sector delivers up to 70% of healthcare in Nigeria, so why are partnerships with the public sector still so hard to scale?
In this episode, Njide Ndili joins us to break down what it actually takes to move public-private partnerships from buzzwords to real, working systems.
From financing and policy to trust and execution, this conversation explores the foundations needed to turn healthcare innovation into sustainable care.
Season 2 is about Building the Rails and this is where it starts.
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Hello, healthcare enthusiasts, and welcome back to The Cure. This is the podcast where we're revolutionizing the business of healthcare in Africa one conversation at a time. I'm your host, Tim Tobekoka. In each episode, I sit down with the people shaping the future of healthcare in Africa, from founders to investors to policymakers and beyond. Our goal is to infuse hope back into the narrative by spotlighting the progress and momentum that's already unfolding across the continent. At the heart of every episode is one key question: What does it take to revolutionize the African healthcare business model? All our insights are powered by TC Health, your trusted source for healthcare and pharmaceutical insights in sub-Saharan Africa. This is part two of our conversation with Mrs. Injude Indilee. She is the president of the Healthcare Federation of Nigeria, the largest coalition of private healthcare stakeholders in the country, and also serves as the country director for Farm Access Foundation in Nigeria, an international NGO that has been on the ground for years, building practical PPP models across the country. Our conversation is spanning all things public-private partnerships and what it takes to scale them beyond a pilot phase. So let's dive straight back into our conversation.
SPEAKER_00I dare say that, you know, some of the success is linked to the PPP that we did in primary healthcare level in Delta State. Because we went from zero encounters because the clinics were abandoned, the PACs were abandoned, to over 200,000 footfalls within the clinics. Wow.
SPEAKER_04Wow.
SPEAKER_00Over a period of time. And as you mentioned, zero maternal mortality, um, even infant mortality, you know, there's you the numbers that we were recording were, you know, were shocking.
SPEAKER_04Yeah.
SPEAKER_00You know, so it gave us evidence to be able to make a case for PPP or private sector involvement at the primary healthcare level. So which is why we're currently also trying to engage with uh ALGOM to see how this can be replicated. I've made presentations to the governor's forum. Um, but again, what we are trying to work out is the payment system because of course the private sector needs to be paid on time.
SPEAKER_02Yeah.
SPEAKER_00And if the funding is with a government agency, then you know there are delays. And the private sector, you know, they they they have to have you know uh uh what I'll call consistency in the fund flow for them to be able to pre-plan and to run their operations efficiently. So um, so yes, it's it's been an interesting um interesting journey supporting uh Lagos State, especially. And I m I must say that Lagos State is unique in the sense that the people in on the government side are very enlightened and very passionate.
SPEAKER_04Yeah.
SPEAKER_00So it makes interaction easier, yeah. But then um it's all about the speed of execution, yeah, the speed of um you know implementation as you call it, to make sure that uh it's it's sustained and scaled. Yeah, yeah.
SPEAKER_01I have so many follow-ups. I will try and streamline them into two. The first one is you mentioned that it started off as a pilot. If you could summarize what were the most important factors from transitioning from pilot to a wider scale with that PPP with the Lagos state government, I would love to understand that because I think that's where a lot of PPPs go to die after the pilot phase, you know, just there's a slow death. So I'd love to understand what was the most important factor that drove that pushed it from pilot to now it's something that's now kind of being widely implemented. That's my first follow-up. Um, I'll resolve my second follow-up. I'll let you answer the first one. Yeah, yeah, yeah. The second one is not related to that.
SPEAKER_00So the the most important thing I must say is co-creation and ownership from day one. Oftentimes donors and uh international organizations bring a cooked meal to the table. No. You want to make sure that you're co-creating, you're co-designing, your priorities, you know, and so that they take ownership from day one. That's how we've always worked, uh, especially with Lagos State. So it the transition is very easy. Yeah. Uh because already you're doing the work. We're just we're only supporting you. Yeah, we're not the ones doing the work. So we tell you, you know, this, that, that, yes, we may bring some funding to tests, but it must be your ownership, your staff, you, you know. So that's really how we've managed to keep it going and to scale it. And another uh aspect of it is when we started this pilot, um, by the way, we started it simultaneously, Lagos Anquara. Um we knew that because it was a new intervention, yeah, that we had to prove that is the right thing to do. So we we backed it up by operations research, yeah, and an impact, which was published. The fact that this is the result of um improved care, improved health, yeah, because of insurance, and that it must be um mandatory, so on and so forth. And we worked together with the World Bank Health in Africa Initiative to help develop the policy, which was then passed at the National Council on Health.
SPEAKER_04Yeah.
SPEAKER_00As you know, the National Council on Health is the highest policy-making body. That is where, you know, it was, you know, kind of given a check mark.
SPEAKER_02Yeah.
SPEAKER_00Um, that, okay, this makes sense. And then, you know, maybe we need to pass a law. You know, so initially started by the National Health Insurance Uh Law Act. Then it transitioned to a state-support health insurance scheme because we found that, you know, when it's national, some states were complaining, you know, we're remitting money to federal and our people are not getting covered. So it now devolved into a manageable state-supported health insurance scheme with some counterpart funding from the state. So that really informed um sustainability. Yeah, you need to back it up by law. You need to back it up by specific pillars. Um, so one is to ensure that you have um percentage of your consolidated revenue designated and and put into an equity fund to cover those who cannot afford to pay. Lagos unfortunately has 69% based on the statistics. People living on less than I think now one dollar or two uh what one point one dollar fifty or two dollars a day. Um but below the poverty line. Yeah. So it's a lot of people. Yeah. And where that becomes a problem is that the responsibility falls on the state to take care of those. But again, you can take it one step at a time. Yeah. In fact, we even developed a poverty mapping tool, which is uh uh PPI2, progress out of uh poverty index, which kind of grades your where you are in your poverty to know who should be fully covered, who should be subsidized, and so on. Otherwise, everybody becomes poor.
SPEAKER_05Yeah.
SPEAKER_00And the state has to bear that burden. So enshrine it in law to make sure that it's um, you know, when the the regime transitions is still there to is ownership uh to ensure that the people within the government agencies that are co-creating and at the table when it's designed. So they are giving us input into the baseline of what really um, you know, they want, you know, uh to back up you know some of their own design. So it's not oh farm access brought a solution to you. Um third is you know, how do you structure the financing so that it's seamless? You know, oftentimes the barrier is not being able to get the money out on time, you know, when it's in government coffers, you know, there's a process of procurement process or however the money is released. Yeah. You find that is so how do you structure um, you know, the agency, um, build their capacity? We did a lot of capacity building. In fact, we have a healthcare management program at the Lagos Business School Enterprise Development Center, just focused on training both government and private sector owners how to run their uh operations as a business.
SPEAKER_04Yeah.
SPEAKER_00It's not really that you don't have to be a for-profit to run properly because you must be able to sustain yourself or at least break even to be sustainable. So those kinds of capacity building uh we did. So the the uh the uh DG of um Alashma also passed through that program. In fact, the whole health service commission sent the entire C you know leadership to that program. So these are the kinds of interventions that help, you know, ensure that there's transition, yeah, there's sustainability. In fact, right now, farm access is not really supporting except on the supply side because we're still working with um LASHMA on their quality building capacity of their assessors to maintain the safe care assessments and the program to ensure that quality continues to rise, even in in the face of the moving personnel that are uh uh jackmarring. So yeah, so it's it's very intensive. Yeah, um, very intensive. And we we're doing this not just at the agency level, uh, because we feel that um the governance and the policymakers need to understand the ecosystem. Yeah, you don't understand, you can't really regulate properly. Yeah. So we worked with Hefama, which is the health facilities agency, regulatory agency. We worked with uh PCN, the Pharmacy Council of Nigeria. We worked with the Health Service Commission. We worked with uh LASHMA, as I mentioned. I mean, literally all the agencies, we had to, you know, ensure that they're all aligned. And we don't forget at the end of the day, the patient is the one in the middle. Yeah. So we it's how do we see a system or build a system that is affordable, you know, quality of care is good, accessible, where they are.
SPEAKER_04Yeah.
SPEAKER_00Um, you know, even at some point we had to do a GIS mapping to understand where all the facilities in Lagos State were and what is within those facilities, both the public and the private, yeah. And where they're located, and juxtapos that around the population. Yeah. And look at where then there are gaps in care provision, where there are no PhCs, and all that we we had given uh to the commissioner of health at the time, you know. So we've we've done a lot over the last um I would say 12, 15 years with Lagos State.
SPEAKER_04Yeah.
SPEAKER_00Um, but we, you know, we're still not there. Uh but it it's it's a very difficult journey that um, you know, we we just have to keep going until we get it right.
SPEAKER_01Yeah.
SPEAKER_00Yeah.
SPEAKER_01Oh, every time you speak, I have a thousand follow-ups. But I think I really enjoy the analogy of don't bring a cooked meal to the table in terms of co-creation. And you know, we often have this term of the too many cooks in the kitchen, but for a PPP, it's really sounding like you actually need a lot of cooks in the kitchen because I'm hearing a lot of interagency stakeholder engagement and management that kind of drives a PPP. Because when you are coming from the private sector and you know, the public sector wants you want the public sector to implement a certain policy, it's it's like you've approached one sector within the public sector, one agency, but for that agency to accomplish that, they also liaise with another agency and then another. So it it sounds like maybe that saying of too many cooks in the kitchen is actually in the affirmative, where within a PPP, it it does sound like because even with the um import waiver for APIs, the number of different agencies that eventually had to all come together. Um, yeah, it's it's super interesting.
SPEAKER_00I think I think that may actually be one of the biggest issues that people don't know about.
SPEAKER_01Yeah.
SPEAKER_00Um, you know, it's because our finding is that it doesn't just rest with one agency going to talk to the Ministry of Health or talking to the health insurance agency.
SPEAKER_04Yeah.
SPEAKER_00I think it cuts beyond that. Another example I'll give you in another state where we were working is we actually helped, um, first of all, again, we helped to get the health insurance bill passed. We helped with the budgeting to determine how much should be put in the state budget to cover some of the activities that had been defined. And of course, nothing happened. So, why is that? It turns out that the the agency within the Ministry of Finance that was supposed to release the funding had no idea what that is. So they just overlooked it. You know, so all of a sudden we opened our eyes to the fact that Ministry of Finance needs to be, you know, in the room with health.
SPEAKER_04Yeah.
SPEAKER_00In fact, they need to be signed, if I put it that way, because you appropriate and it doesn't get released. Yeah. We also had the statement from uh the current coordinating uh minister of of health, uh uh uh Dr. Patty. Yeah, that his budget was it 216 billion and only 36 million was released.
SPEAKER_01Less than 1% released. Yes, yeah.
SPEAKER_00So so the point is what is that process? What do you have to make a case to the Minister of Finance? Do you have to justify? Yes, it's in the budget. That doesn't mean we're going to give you the money.
SPEAKER_04Yeah, yeah, yeah.
SPEAKER_00There must be a process. So how if if they don't have a handshake, yeah, we're going absolutely nowhere.
SPEAKER_04Yeah.
SPEAKER_00You know, so that mean interministerial, especially with PPPs, by the way, I've never really seen a framework for PPPs. I mean, I know there's an ICRC at the federal level, but again, remember that health is on the concurrent list, as they say. So you're dealing with so many agencies and state. So federal is tertiary, uh, secondary is uh state, uh, local PhCs is local government now. So at each level, you're dealing with different stakeholders and different policies. That's why policy regularity is so critical to PPPs and their sustainability or their success. So it may work in one state, it may not work in another state, you know. Yeah, it worked in uh Delta State, it didn't quite work in Lagos State, yeah, you know, so it's all around policies and um clarity for the private sector. The private sector always wants um clarity of regulation, consistency or assurance that if they invest, their money is not going down the drain when the new regime comes. So, how do you ensure that there's consistency? Of course, the market. So there's certain factors. So if you want me to build a hospital, is there health a policy that makes health insurance mandatory? Is it enforced? Yeah. Are the people able to pay and so on and so forth? So there for the private sector, there's there's certain you know, uh um boxes that need to be checked before they can actually throw all their money in. You know, and these are where alignment of incentives is so critical in PPPs. Yeah, what does the government want? What does the private sector want? Yeah uh we is this structured in such a way that your incentives are being catered to. So, you know.
SPEAKER_01Yeah. Again, I go back to your analogy about you can't bring a finished, a cooked meal because it's like it's gonna sound so random. If you want to make effort with someone, some people like their effort really spicy, some people like lots of palm oil, some people like minimal oil, some people like to add ougo, some people don't like you have to come together and decide. What are we putting in this effort?
SPEAKER_00Exactly, exactly.
SPEAKER_01Yeah. Um, another example of a PPP, and you referenced it in Delta States, the revitalization of um primary healthcare centers. This was through your access to finance scheme, um, where it's like a framework designed to encourage PPPs between state government and private healthcare providers to provide affordable and quality healthcare in government-owned facilities that are defunct, abandoned. There was a documentary on YouTube that I watched, I go, I go into rabbit holes, but there was a documentary on the Farm Access page on YouTube about this scheme. And I saw the video of what the first visit to a PhC center. First of all, it was surrounded by weed. Yes, by just so much vegetation, and then inside just pools of water, everything, you know, ceiling leaking and stuff. And I was like, wow, like those are the government facilities that are then revitalized, and then at the end, you kind of see the like product. It was pretty cool. Um but the idea is to kind of revitalize those types of facilities. Um, so bringing in that private sector funding to then kind of allow that goal to be achieved, and also bringing in the government's insurance side of things. So you already mentioned Delta State. Again, pull back the curtain. How was this um take us behind the scenes of how this happened? And in that documentary, I I there was a there was a member of the pharmacist team that was talking about needing to go to even community leaders within those local government areas to almost get them on board. Yes. You know, you think, okay, it's a who doesn't want a PhC revitalized, but you know, there's so many different stakeholders that come into the mix. So I'd love to pull back the curtain on that one as well.
SPEAKER_00Well, that's a very interesting one. And um, if I were to end my career, I would want to see that scale as my my only if I was to pick one thing that I want to accomplish in my career, it would be bringing the private sector to run uh public PhCs. Um so in Delta, uh we were supporting again, similar to what we did in Lagos, supporting their health insurance rollout.
SPEAKER_04Yeah.
SPEAKER_00Um, but very quickly we found that you're asking people to sign up for mandatory health insurance and pay, but there's no clinic around them. Instead, there's a rundown old PhC. Yeah. So um interestingly, the DG of the Delta Commission uh insurance commission at the time was also a forward-thinking person, Dr. Ben Ben and Kechika. So we came to him and said, Look, we can, you don't have to spend your money. We will bring the money from uh medical credit fund in partnership with Bank of Industry to give private sector funding to revitalize, just give us the ones that are not uh that are run down, nobody is using, yeah, just so that we don't have any issues with civil servants saying you took away my clinic.
SPEAKER_04Yeah.
SPEAKER_00And that was what he did. He gave us some NDDC clinics, um, some that were quite run down, some as far out as two hours by speedboat into the creeks of the Niger Delta.
SPEAKER_04Wow.
SPEAKER_00And it was an eye-opener. Um, what we said to him is that look, we will bring in uh private operators who already have experience running hospitals. In fact, it was in partnership with the Healthcare Federation at the time. We put out a call for people to uh uh indicate interest of running uh a primary healthcare center. Yeah we selected uh about six uh private providers, most of who didn't even have hospitals in Delta State. Most of them were Lagos-based or Warri-based. And um we gave them uh loans uh through the Medical Credit Fund and Bank of Industry to revitalize on the premise that uh one, um, there will be uh enrollees assigned to them from the mandatory health insurance scheme, even if it were indigents, yeah. That were being paid for by Delta State. Uh, two is that they will have safe care embedded within the clinics. Um, and three is the fact that, you know, they'll run the the PhCs and when it becomes profitable, they can split, you know, the Profits with the state. It was kind of build, operate, transfer, build, operate manage, I forget the term. And that's how we started. So basically, we some of them didn't even need revitalization. The ones that were in far um in the creeks of the Niger Delta, two in particular, was being run by Dr. Eze, who is the owner of Toronto Hospital in Onicha. And he used the um oil industry two weeks on, two weeks off to move the medical crew. So two weeks on, yeah, um, to manage a clinic that had actually been donated, built and donated by Chevron 15 years ago.
SPEAKER_04Wow.
SPEAKER_00Everything was still intact, locked, nobody to operate. And then, you know, they started uh operating. Fantastic um uh results that we were seeing. Um people started all of a sudden the clinics were full. Palon Memorial in Lagos here was running two. Um, Outreach Hospital in Lagos was running uh one or two, I don't remember. SFH. These are experienced operators.
SPEAKER_04Yeah.
SPEAKER_00And it takes uh takes you back to the model used in the US, yeah, where you uh you have hospital systems, Kaiser Permanente, Christus and Elizabeth, you know, they're run because it helps you manage your quality, helps you manage your purchasing, bulk purchasing, yeah, it helps you manage your personnel, you know. So it's like a system, it's like a franchise system that helps you manage. So that was the whole idea behind that. How can we get um experienced operators to come in, bring their expertise, their efficiency into a government-built uh PHC? And that was what we did. And the results phenomenal. We have an impact evaluation that was done, which was also very um revealing. Not only the fact there was zero maternal mortality, um there were some learnings too. For example, in the rural areas, pregnant women uh they often have market days. They wait till they, you know, I have to sell market. They wait till the end of the day before they, even though they're in labor, before they go to the hospital. So they usually end up in the hospital after dark. There's no light in the PhD. Then you can imagine what happens.
SPEAKER_04Yeah.
SPEAKER_00But all of a sudden, because these are run by private sectors, 24-hour care, yeah. In fact, Shell, I think, donated solar panels, you know, good things were aggregating around those PPPs. Yeah. All of a sudden, people were coming in, we were delivering babies to the extent that one of the providers said, look, we have to do some family planning, we have to do some family planning education here because the the birth rate is so prolific and and all that. But the fact that um, you know, the there were specific anchors to the system. Again, yeah, the fact that you had uh a committed uh leader in government who took ownership of the program.
SPEAKER_04Yeah.
SPEAKER_00He wanted to make sure that it worked. Two was there was a clear alignment of incentives. The private sector at the time were getting paid.
SPEAKER_04Yeah.
SPEAKER_00Um, you know, the numbers were coming, they were supplying them or giving them enrollment basis. The patients were happy. Yeah, you know, so so all of a sudden you see a system that is working uh on the back of a mandatory health insurance scheme where those who couldn't pay were being uh covered. Yeah. Not just through, I think they had a lottery fund, but also the basic healthcare provision fund.
SPEAKER_04Yeah.
SPEAKER_00You had quality embedded in the PHCs. You you know, all we checked all the boxes.
SPEAKER_04Yeah, yeah.
SPEAKER_00You know. Um, but of course there were delays subsequently because for for pharmacists, it was just a proof of concept.
SPEAKER_04Yeah, yeah.
SPEAKER_00The fact that this can be done is somebody now needs to take ownership. So we exited in terms of you know stepping back at some point because we had done our impact evaluation, we had advocated at you know the governor's forum and uh different places. So it's now who is going to scale this?
SPEAKER_04Yeah, yeah.
SPEAKER_00What's the modality for scaling, you know, and things like that? And I think some of those discussions are currently ongoing. But that's really how we came about uh that scheme. The fact that at the primary healthcare level, it's not that poor people or indigents don't know what quality is, yeah, but it's just that it has to be infused into the system for them to come. Some of them were even willing to prepay uh or pay for their care out of pocket, which we try to discourage. But how do we create that pathway? Create transparency, efficiency. Um, government really doesn't have to be the one running. It saves you cost on um your staffing, it saves you um a cost on you know equipment and and things like that. You don't really need all that. And something else I want to mention is the fact that through our impact evaluation, we realized that the amount of money that was being channeled from government to those PhC was even though it was a lot of money, like one million, two million a month, it was insignificant to the quote to it it didn't make a dent in terms of improving the overall efficiency. Yeah, you understand? So you're putting money into a hole and you're not seeing the results. So you need to actually increase the quantum of funding made available to a PhC. And then for how long, if it's coming from government, meanwhile, private sector can generate its own funding. Yeah, there were, in fact, one of the um PhCs, I saw where they were giving old people um exercise lessons. There were about 30, you know, so all of a sudden you you create a community, the food power. Yeah, um, so people are coming to charge their phone, somebody was selling food. Wow, all of a sudden a PhC becomes a community center.
SPEAKER_01Yeah, yeah. Wow.
SPEAKER_00You know, so these are some of the ideas that private sector comes with. You know, um, they don't have to uh you know they aggregate their their problems or their you know, they try to aggregate for efficiency. Yeah, both buying, you know, what you do here, do it there. If I'm buying for this clinic, I buy for the other clinic. If I'm trying, so you know, it it's it's almost a no-brainer. Somehow it remains extremely difficult. Yeah, you know, so we proved the case, we wrote an impact evaluation report, we made it available, it's even online. Yeah, um, so what we're waiting for is how do we uh implement policy or how do we scale this so that it's not in discussion, it's not um uh sign an MOU ceremony, but rather execution. Yeah, you know, I think that's still the bridge we need to cross.
SPEAKER_04Yeah.
SPEAKER_00In fact, at some point we brought in uh Lagos Business School to help when uh HFN visited the governor's forum to help what is it that is really uh stopping this uh fantastic framework from scaling?
SPEAKER_01And what did you find? Um because one of my questions was going to be how do you take this from 15 facilities to 150 to 1500 to 15,000? How do you what's that binding constraint? So the constraint uh uh twofold.
SPEAKER_00Uh one is um uh what would I call it money fund flows. The private sector needs to be uh paid on time, they need to the that there has to be transparency around the funding. Yeah, and sometimes you know with governments they say, oh, it went into a TSA account. Sometimes the private sector doesn't get paid for up to four months, right? And they are not willing to take up any new ones. In fact, a lot of the private sector providers or operators started seeing this project as a CSR because they were running it on their own, yeah, on their own funds. Um, so that was the one thing. What is the right structure for fund flow? Do you take that funding out of government? Can you have an independent agency that holds the insurance premiums so that they're better able to manage the scheme? Yeah, that's still up for question, whether government will agree to that or not. Yeah, you know, so that was one main thing. Another thing was technology. Uh, the fact that uh transparency oftentimes wasn't very uh present. Yeah. The fact that some of the clinics were so remote that you know you had to do a lot of things online.
SPEAKER_04Yeah.
SPEAKER_00Um so how do you ensure that there's that connectivity that creates a flow? You know, in the beginning, I talked about the healthcare system being an ecosystem.
SPEAKER_04Yeah.
SPEAKER_00There has to be transparency, there has to be data flows, there has to be uh uh transparent financial flows, there has to be connectivity. Everybody has to, if the patient goes here, you know, it reflects somewhere, yeah, so that that way the system is integrated. So that was lacking. So at some point there was, you know, oh, they're owing me. Did he come here? He didn't come, uh, you know, questions around who who are you treating, yeah. Who visited the hospital and when, you know, and and things like that. So it still remains a problem.
SPEAKER_04Yeah.
SPEAKER_00And I the third I would say is um a bit controversial, but public sector is is a bit territorial, right? Um we heard cases of government saying the staff in the PAC say, no, you want to come and take my job. You know, private sector wants to come and take my role and you know, things like that. So you begin to wonder, you know, how do you approach this? You know, but I've always said you don't have to start with all of this, just start with the ones that are non non-functional. Yeah, yeah. You know, so again, these are some of the discussions that are ongoing with uh Algon, which is an association of uh local government uh chairmen. Um all private sector can do is create your efficiency. Yeah, you know, help you uh build your capacity, help you put in systems that will create efficiency. Um, and if we've replicated that model, really you can take the funding you're getting from government and pay premium instead of upgrading the facilities. Yeah. Really. Um and you know, we've had discussions with the likes of um Africa Development Bank where they were very interested in the Delta program because of the impact at the grassroot level. But unfortunately, entities like that are looking to give big money $100 million, 10, you know, $50 million. But I will tell you that when we started, just to get one of those PhCs up and running didn't cost even 30 million. You know, so there's small amounts of money that um larger uh development finance banks are not willing to, you know, they think it's too much work. They tell you, you know, if I give you $10,000, it's the same amount of work I need to do if it was $100 million. Yeah. So why would I waste my time on this small amount of money? So um these are some of the challenges really, but um, I think there's hope. There's there's a lot of work, a lot of opportunities, yeah. Because I'm I'm sure you know that there's over 30,000 PhCs, yeah. Of which less than 30s, 30, yeah, yeah, are functional. Yeah, and by the way, I even questioned those numbers because when we went into Delta State, there were PhCs that the government didn't even know existed. Constituency projects, when they saw what we were doing, said, Oh, I have an abandoned PhC. My we said, no, we didn't see any abandoned PhC, so don't worry, I'll build one and abandon it. I mean, you know, so things like that. So it may actually be more. Yeah. Because with the tendency is bricks and mortar infrastructure rather than systems that help uh enable access to care.
SPEAKER_01Yeah.
SPEAKER_00Yeah.
SPEAKER_01And I I have to conclude this section, I have a hard question. Nigeria is heading into an election cycle. And we've already seen what happens with PPPs that maybe, like I think there was a PPP maybe in Quara States where it was praised by the UN Secretary General, but there were some disruptions when the political leadership changed. And how do you ensure this continuity when power is now changing hands, or we're gearing up for power to potentially change hands, or reshuffling of who's appointed to where, etc., and in this new kind of um election cycle. So how do you how do you prevent those initiatives from getting stalled during these transitions or you know, political cycles then impacting the continuity of PPPs?
SPEAKER_00Well, uh, that's a difficult one because that's my leaped experience. Um the only thing we thought to do is to ensure that there's policy backing, uh support, the work that we do, so that it's difficult to wipe it away. Um what you talked about that was praised by the UN was actually Aquara Health Insurance Scheme. Um you know, it we at some point was the largest PPP uh insurance scheme in sub-Saharan Africa. Okay um but at some point we had to stop because we needed to make that transition uh to the new administration. In fact, for almost a year we we couldn't engage because they were trying to settle down, we didn't know who to talk to. Eventually, we identified um a person who uh luckily was kept from the previous administration, so the scheme uh kept going. But it is the most difficult uh barrier that this kind of projects face. So to solve it is really a policy, yeah, uh, or dealing with the institution itself, yeah. That is dealing with the agency, maybe not the the top layer, but then ensure that the the next tier is involved and buy into the project that you're running. Yeah, yeah. Because oftentimes the the the DG is removed, but the core civil servants remain remain. So to ensure when I talked about co-creation that they're involved and so on and so forth, that's the only way, but even then, it's still a very difficult uh uh challenge that we also don't quite have a solution for, anyway. So again, it goes back to policy.
SPEAKER_01And we'll see, you know, as we're going into an election cycle, I'm sure there's all sorts of you even mentioned ongoing conversations about how to expand this program. I guess lived experience will tell, you know, how how things transition. Um now I want to shift to something that sits underneath everything we've discussed, which is trust. Um, you've referenced trust as being the currency between all the different stakeholders and PPPs. We've talked about, you know, patients actually trusting the healthcare system. Um and quality has come up quite a lot. And as we say, the private sector is building the rails, and as part of that, has this intersection with a lot of different patient types, etc. I would love to talk through what Farm Access has been working on. So Farm Access has been working on this building of quality, building of trust through safe care, which brings internationally accredited quality standards to the African healthcare reality. Um, given this landscape where I would say trust in formal healthcare is fragile, but it's kind of a weird uh oxymoron because a lot of Nigerians bypass formal healthcare and seek medic medicine from traditional healers, etc. So there's trust where there's no um regulation, but where there's regulation, there's might not be as much trust. So I'm I'm curious to hear about what safe care is doing and what safe care has been able to accomplish in the context of this landscape.
SPEAKER_00So so this is where you know pharmacist has really made its mark in the healthcare sector. Uh so safe care is a quality improvement methodology. I mentioned this several times. It is um a set of standards that was developed by Pharmaccess in collaboration with Joint Commission International, JCI, based out of the US, and KOSASA, which is based out of South Africa, uh, pretty much to create a formal way to benchmark um health facilities in resource-restricted countries or settings. Uh, usually in the US, JCI, you passed or you failed, right? Um but what we're doing is trying to take these standards and localize them within our context, the African context, where you know it's practical, it's it focuses even on our culture, our behavior, the way the patients uh, you know, see healthcare, where they seek healthcare. So um it is uh incremental, it is uh in the local context. It is not for even though it works in big hospitals, but it could also work, you know, you can apply the standards to smaller settings. So we have levels one to five.
SPEAKER_04Yeah.
SPEAKER_00Um the likes of Paylor Memorial is on level five, and it applies both public and private, which is interesting because you can cut across any healthcare facilities. So that way you're better able to benchmark.
SPEAKER_04Yeah.
SPEAKER_00And the focus is on um, you know, the skills, the equipment, infrastructure, and processes.
SPEAKER_04Yeah.
SPEAKER_00So the infection control, record keeping, ancillary services, you know, there are certain domains that it covers. And what is interesting about it is that, you know, it's not okay, do you have a guideline to treat malaria check? Do you have um uh stethoscope? But it also checks the functionality of some of when it comes to equipment. You have it, it's good, but is it working?
SPEAKER_02Yeah.
SPEAKER_00Do you have a maintenance agreement? Because if it's working and you don't have a maintenance agreement, when it breaks down, what happens? So we try to give you a step-by-step approach and give you tools that will help you to improve quality.
SPEAKER_02Yeah.
SPEAKER_00Right? Uh so we see it as a progression, uh, and it's not punitive. Rather, we work with you. So the the baseline is that we do uh a baseline assessment. That's what we call it. And from there we give you a uh quality improvement plan, what we call QIP. It tells you where all the gaps are in your facility and what you need to do, right? We also progress into mentored assessment. So mentored assessment is where we can actually work with you to fix all those gaps. Or you can decide you want to do it yourself. Yeah, you know, but that way, you know, you can move, you see progress, you see, you know, you have an incentive to improve quality. We also now started putting uh some of the providers in community where they can communicate amongst themselves, yeah, you know, so they can cross-learn. Um, but it's been interesting because this is the first um of its type that was accredited by ISCOA. ISCOA is the international quality accreditation body. So they accredit the accreditors for resource-restricted countries. No, I think there are a few more. Um, and we are in over 27 countries, um, in over, I think, 10,000 clinics. In Nigeria alone, which is where we started, this is where the standard started, by the way. Um, you know, we have a lot of um, you know, hospitals that have are currently implementing. Yeah, and I must say that we are the backbone of the National Health Insurance Authority. So Safecare is being implemented and cascaded to the 7,000 B A CPF facilities. And we are training uh the NHIA staff to own it. So we, you know, we try in the past we would do the assessments and work with you, but now we're trying to find partners that we Would help uh take it on, yeah, build capacity, and that's the only way we can scale. So it's important for us now because quality remains at the core, the center of us achieving universal health coverage. It's the arrowhead.
SPEAKER_04Yeah.
SPEAKER_00If there's no trust in the system of the quality, then I don't think people will prepay for healthcare. And also what is good is the fact that we are taking it not just from the formal healthcare providers, we're taking it to the informal providers. So, you know, we're where we have um what we call uh pharmacy tools that we can deploy within pharmacies, we where you know we work with different uh associations and agencies to ensure that you know our standards are fit for purpose and it's improving quality where the people are going.
SPEAKER_03Yeah, yeah.
SPEAKER_00Where they're already going. How do we ensure instead of you know, I'm shutting you down, yeah, you're not uh, you know, but rather how do we work with them to ensure that they improve the quality or we embed them and create a linkage into the healthcare system? Oftentimes what is happening in those um uh providers is invisible, nobody knows. So we're trying to make those linkages using digital tools, uh using training and advocacy to ensure that they're you know, we're creating linkages into the formal healthcare system. Otherwise, yeah, you know, the the nobody recognizes them.
SPEAKER_01And I'm curious, what is something that you have seen in terms of like a before and after that would bring this to life for our listeners? Like taking a healthcare facility from level one to level three or four or five, like how is that?
SPEAKER_00Yeah, the the biggest example I can give is FMC Abutemata. It's a government tertiary facility. We worked with them for four years, and you know, I myself, the only hospital I've been admitted in was in FMC Abutemata. Really? Yes. So this is a hospital that is now paperless. It's a hospital where the uh chief medical director that we worked with has even transitioned out, but the system still remains because of how we worked with them. When we started, there was a way doing the vaccine fridge. You know, I mean the before and after is clear. And because of that, every minister of health that takes on that role visits FMC AbutaMeta as an example. And as a result of that, the uh the Minister of State for Health has actually assigned 48 other tertiary hospitals to pharmacist to work with to see how we can transition and because it's now a center of excellence.
SPEAKER_06Yeah, yeah.
SPEAKER_00Yeah. So how can we replicate what we did in FMC Abutemeta across uh 48 other tertiary facilities? So that is the biggest example. Uh I always tell people go there, look for yourself, yeah, see what we're doing. Yeah, but again, it's not stagnant, it has to be maintained. So the proof is now going to be in how do they maintain the quality that we've uh embedded within the system. But yeah, that's that's that's just one example. But there are many more.
SPEAKER_01Yeah. And and I'm I'm curious what is some of the biggest challenges with Nigerian healthcare facilities improving their quality. Because I I want to believe that every person or medical doctor, whoever that starts a facility or builds a facility, has the goal of providing quality care. Nobody, I hope, has a goal of providing substandard care. But there's obviously challenges that get in the way of that goal. So I'm curious what exactly are those challenges? As you've seen the implementation of safe care throughout all these different facilities, what like prevents hospitals from or facilities from improving their quality?
SPEAKER_00So, so first of all, um leadership accounts, right? The medical director has to buy into the fact that he doesn't know everything and that he has to put in a system that puts guardrails around you know his facility in terms of implementation that includes the staff, the staff you you hire, the systems you put in place. You know, all this has really an impact on the ability to scale quality. But what is also more important is access to finance.
SPEAKER_04Yeah.
SPEAKER_00The fact that, you know, a lot of hospitals are still treating patients out of pocket. So except you have institutional funding, you're growing organically.
SPEAKER_04Yeah.
SPEAKER_00You know, you're, you know, the the doctor is the receptionist, is the anesthesiologist, and you know, it's really small SMEs, owner-founded um facilities. So it puts a huge barrier. If there's no income, constant income stream from insurance or from you know, out-of-pocket is subjective and it's flu it can fluctuate. But if there was constant income, then you know it can give you predictability around your operation. So I think that remains a big challenge. In fact, what we're seeing now is a lot of hospital closures uh from owner founded, yeah, whose kids have jackpad, they don't want to run the hospitals, and then you know they they they're stuck.
SPEAKER_04Yeah.
SPEAKER_00So there's an entity right now that is mopping up all those facilities and creating a hospital chain. Oh, yes, uh, very interesting model as well. And I think it's one to promote.
SPEAKER_04Yeah.
SPEAKER_00Their name is K1. You can also look them up, uh, and they're also part of HFN. Okay. They were also part of the access to finance and delta. So I think that's what gave them the idea. Yeah, so they're now taking it to the private sector side to aggregate those types of hospitals, and you know, so I think that's really what it is. Uh, finance, uh, staff retention, power, yeah. So some infrastructure um, you know, foundation that is that makes it difficult to maintain the level of quality, it's expensive.
SPEAKER_03Yeah, yeah.
SPEAKER_00Have the right equipment to follow the right clinical protocols and do the right thing. When somebody comes in with a fever, you do the test first before, you know, that there's certain clinical protocols that you would follow, but you know, again, it's all about financing. We find a lot of uh providers try to cut corners because the patient doesn't want to pay, you know. So this has a vicious uh generates a kind of vicious cycle, you know, and it ultimately affects the quality of care that is delivered. So um, and that's what we're trying to walk around. Yeah. So with for example, with safe care, when we say you for infection control, that you must have running water. So it doesn't have to be that you have a borehole, and it can be a tank, but it has a tap so that when you open it more, water runs. Yeah. Right? So, how do we localize some of the solutions to fit within our context?
SPEAKER_01Yeah, yeah. And, you know, now that we've talked through the landscape, the composition of the private sector, the realities of building PPPs on the ground, and now we've talked about trust. I want to pause and put you to the question that sits at the heart of every conversation on this podcast. What does it take to revolutionize the African healthcare business model? This is our like blue sky question. More specifically for your world, when we think about PPPs and healthcare, um, you have decades of pilots, frameworks, MOUs. Some have worked, some have scaled, most haven't. What does it actually take to move from that partnership as a buzzword or pilot, several pilots, to partnerships as the operating model for healthcare delivery in Nigeria and across Africa? Blue sky.
SPEAKER_00Yeah, so first of all, we have to take away the notion that healthcare is a social benefit. It is an economic investment in any economy. So we have to start you know shifting that mindset that uh health is a business. Yeah, right. If we start with health is a business, it will deep it will restructure the way we interact. That's the first thing. Second thing is that the private sector is not an afterthought. It has to be integrated. Yeah. You know, the likes of the banking sector, the um power sector, all those were revolutionalized because of private sector innovation, the new ideas that they brought in. When Lazid do write a check for a bank, in fact, when Lazidu walk into a bank, everything is done online. What stops the health sector from thinking from that perspective?
SPEAKER_04Yeah.
SPEAKER_00Um the uh DTH lab, which is digital transformation of health labs that I'm involved in, is looking at health as click and brick. In fact, we've developed a new framework of uh the healthcare system of the future. So it's a digital framework.
SPEAKER_04Yeah.
SPEAKER_00Because maybe we don't need to even walk into a hospital to consult with a doctor. So it's really uh seeing the healthcare uh sector or space as one that needs a lot of innovation allows the young people to come to the table. We have to be deliberate about creating space for them to come to the table and help us design the healthcare system of the future, you know. Um, because you know, we're doing well in every other sector, fintech, you know, the young people are busy doing podcasts, you know, they're doing all sorts of things. But when it comes to health, you know, the young people are not seen.
SPEAKER_04Yeah.
SPEAKER_00And we leave the system for analog leaders to design a healthcare system for the youth growing up in a digital world. So the young people need to step up, or we need to be deliberate about bringing them to the table.
SPEAKER_04Yeah.
SPEAKER_00So that's another thing because their ideas can actually help change the way healthcare is delivered.
SPEAKER_04Yeah. Yeah.
SPEAKER_00You know, so that's another thing. The third is uh finances. How do we create um, you know, a financing structure or allow finance to flow to healthcare? Because without the finance, it's not going to be sustainable. The fact that it's really a system that's anchored on finance is anchored on people, you know, talent and and uh, you know, infrastructure, and they must work together. Yeah. You know, my background as a uh computer scientist tells me that, you know, in a system, each component can be very good. But if they're not working together, it doesn't matter how good that one component is, it falls apart. And that's the way we need to start looking at it. So a system where the private sector is integrated, the people trust the system, you know, their digital innovative ways of accessing care, telemedicine, you know, other ways, maybe some we don't even know about today.
SPEAKER_04Yeah.
SPEAKER_00You know, that is the healthcare and meeting people at their point of need. So it's not about the big hospitals, yeah, but how do we integrate the smaller informal healthcare providers into the system? Right? Because really, you can't in resource uh rich countries, they have big hospitals, hospital systems here and there. I don't think they have all these uh uh uh bed homes and things like that. But this is our reality. Yeah. So how do we make the our reality work for us?
SPEAKER_02Yeah.
SPEAKER_00So I think those are the the you know the themes we need to start thinking about. How do we utilize and create efficiency around what already exists instead of shutting down, penalizing, you know, uh and removing them from the system where there's going to be a vacuum and it creates a you know a downward spiral for us for our people.
SPEAKER_01Yeah. So you've just painted a picture of the blue sky and what it takes to get there. Um, you lead the healthcare federation of Nigeria as the president. Um, and we've meant it's come up throughout this discussion of just the HFN being involved in so many different initiatives. And the HFN has spent a decade building a platform for the private voice of the private sector in healthcare. HFN recently celebrated its 10th anniversary and outlined a very ambitious, forward-looking agenda. But now that you sit in the seats of the president of the HFN, what are the biggest priorities for the next decade? Like where do you want the HFN to go? What are the priorities? What are the goals um to kind of make that vision that you just painted come to life, um, if we dare so say?
SPEAKER_00Yeah. So um uh the vision is very clear. Um, I had outlined a few things that um I wanted to work on. Of course, you can't do everything because the timing is so short. Um, but one is the PPP uh I talked about, especially at the primary healthcare level. If we can replicate that model, it's something that I would love to do. Yeah. Uh we've already started all sorts of engagements, all sorts of discussions, but again, it's left to government to bring us in.
SPEAKER_04Yeah.
SPEAKER_00You know, so that's where the advocacy really is important, making sure that we're in the room. Uh, two is local manufacturing and uh health sovereignty, which is why we have an MOU with PVAC.
SPEAKER_04Yeah.
SPEAKER_00Uh so that we can align. There's so many people working in silos, but if you want to talk to the private sector, can you talk to us? Let's work with you to see how we can get this done. Uh you know, you saw what we accomplished with the API. You know, again, we are the voice. So the the most important thing is aligning the private sector because we're so fragmented.
SPEAKER_04Yeah.
SPEAKER_00And if you watch or look through HFN social media handle, especially on LinkedIn, you see that I've been deliberately um, you know, visiting and trying partnering with the being actively involved in the different associations.
SPEAKER_04Yeah.
SPEAKER_00Last week I was with the medical lab scientists because nobody talks about diagnostics and the issues, the reagents and so on and so forth. Um, the other day I was with the nurses, the other day I was with the community pharmacists. You know, so how do we so we are not competing amongst ourselves, but we are seen as a cohesive coalition of private sector who want the same things. You know, so I think that's what really causes the problem because different people approach government or different issues, and then they deal with just that person, the other person goes, and we're so fragmented. So my job now is really how do we align? Last week, also, was it two weeks ago? I was with NAFTAC again about um you know, regulation around local manufacturing, yeah, and those that want to, you know, start their own new uh manufacturing plants, you know, things like that. So yeah, making sure that we are aligned is very important to me. So that's that's another goal. Another goal is uh data and uh the leveraging technology, which is why I'm pushing really the you know, the DTH lab interoperability. And when you hear me talk, I'm talking about data, data, data. Can we have a data exchange where all that data goes through? You know, when I was in the US, we had huge databases through which Medicare, uh, Medicaid, all that ran through. Yeah, UK is the same thing. Yeah, so can we have that kind of transparency or a data cooperative where you know there's yeah, a ring fence around um the data that enables, you know, ethical movement of the data with the patient's consent? That is very important.
SPEAKER_04Yeah.
SPEAKER_00Because really, I think in the future, the concern has to lie with you and I. Yeah. Don't take my data without my knowledge. So, how do we begin to build that infrastructure? Um, I think that's key. Because without transparency, what are you really uh uh how do you know what who is accessing care, if there's improvement? You can't really know anything, it's all guesswork. So those are the main priorities for me to ensure that you know we really embed uh private sector is not seen as an afterthought, yeah, but at the table, helping develop the policies that are enabling the private sector to grow and support government to achieve UHC. Yeah, you know, so those are some of the things that we should really focus on. And it's it's really there's a lot, so you have to prioritize, otherwise, it's overwhelming. Yeah, and there I say that what I do for HFN is on a pro bono basis. I'm not, you know, I'm doing it just because it needs to be done, and there's no agency right now that is doing what we're doing, yeah. You know, so it's very important.
SPEAKER_01Very, I agree, I agree. Um, we've covered a lot today, and for me, it's been such an insightful discussion. Um, we always conclude with rapid fire questions. So it's a quick question, quick answer. We'll go through just three rapid fire questions. Um, my first question is if you had 50 billion naira to deploy into Nigeria's health system right now, where do you put it?
SPEAKER_00Definitely primary healthcare. Um, because that's closest to the people, that's where they're going to access care. But I wouldn't say give it to government. I would say can private sector help you deploy that money. And that way, you know, we can revitalize uh those PhCs because they're closest to the people.
SPEAKER_01And speaking of PhCs, what is the primary healthcare center you're most proud of revitalizing?
SPEAKER_00Well, I would say the Shonga Clinic in Kwara State. That's the first PhC I went into. And when I went in there, I I went with um then uh Minister of Health. Um I forget her name. When we went in there, there were goats running around. Goats. Goats, yes, you know, pregnant goats. Those goats are always pregnant. Pregnant goats, grass everywhere. And within two months, the utilization went from zero to over 5,000 a month. Wow. Yes, and that is really the start of the idea of a PPP because it was in such a remote area, nobody wanted to go, so we brought in private sector. Yeah, you know. So that that I'm most proud of it. And um, interesting, one of the ladies, young girls, actually, I must say, that uh the first baby that was delivered there, they called the baby Hygiah. At the time I was, you know, the chief operating officer for Hygia when we started that program, yeah. The baby was called Hygiah. It was so inspirational for me because you know, sometimes we do work and we don't see the impact of what we do. But when you come in contact with the lives that you're saving, then you know it means a lot. It pushes you on to continue to do more.
SPEAKER_01And you know, outside of Hygiene context, it's actually a really pretty name. Like, if you didn't know Hygiene was an actual company, I feel like that would be a pretty name.
SPEAKER_00I think it's the goddess of uh health or something. Yeah, like it's it's really pretty, very beautiful.
SPEAKER_01Um, my last rapid fire, what gives you the most hope today?
SPEAKER_00Um what gives me the most hope is somehow I see the lines beginning to intersect. I see the government actually listening. I, you know, the movement is small, but I I I feel there is movement.
SPEAKER_04Yeah.
SPEAKER_00You know, for example, um, private sector is now a signatory to the UAC compact that was signed by all the governors. Yeah, right. Um, HFN was a signatory then. We were a signatory to the power compact that was signed by the government. We are now um allowed to provide care under the basic health care provision fund, private sector. Um, there's finance, you know, available. It's just really now how do we build capacity of the private sector to be able to access that finance? There's a lot of discussion around the same themes, around the same, you know, how what do we do? The fact that health sovereignty now people are looking in because of COVID. Yeah, when we didn't get the vaccines, they realize okay, now you're on your own USAID gone. Yeah, that means donor funding is out the window. Yeah, so it's all about self-reliance.
SPEAKER_03Yeah.
SPEAKER_00So finally, we have to look inwards to figure out how to solve this problem ourselves. So for me, that gives me hope, even though it's a it's gonna be a difficult period, but I think we're beginning to rewire our brains to know that nobody's coming to save us.
SPEAKER_01Yeah, the safety net has kind of been rooting.
SPEAKER_00So the sooner we start rethinking what we can do with the resources that we have, with the talent that we have, because we do have a lot of how do we leverage the diaspora talent as well, and things like that. I think, yeah, I mean, it gives me a lot of hope. And of course, the young people, I keep everywhere I speak, I said the young people, you are in the majority. Don't just sit back, get involved. It's your system, your healthcare system of the future. So help design it. Yeah, so so I'm very hopeful, and hopefully, uh in my lifetime, I will see a healthcare system that works.
SPEAKER_01Amen. Amen. Um thank you for sharing your experience. Honestly, this has been a fantastic conversation. Thank you for talking about the work you're doing. For me, the key takeaway is Nigeria's private sector is the system already. It is providing the majority of healthcare. And the question is no longer should the private sector be involved? The private sector is involved. Yes, right here. And how do we push that forward? Um, for our listeners, you can follow the Healthcare Federation of Nigeria and Farm Access to see all of the amazing work that they are doing. And one more thing before we go, don't forget the cure will be live on the ground at the World Health Expo Lagos from the 2nd to the 4th of June at Landmark Center. We'll be bringing you conversations with some of the most important voices in West African healthcare right from the exhibition floor. So if you're a healthcare professional, a supplier, an investor, anyone who cares about the future of healthcare in this region, you don't want to miss out. So please register to attend the conference. Head to um www.worldhealthexpo.com to register and follow us on all platforms for live updates from the event. And don't forget to subscribe to The Cure and share this episode with anyone who cares about building the rails that make healthcare innovation possible in Africa. See you in the next episode. Thank you, Injide.
SPEAKER_00Thank you very much for having me.
SPEAKER_01Of course.
SPEAKER_00It's been wonderful.
SPEAKER_01Bye.
SPEAKER_00Bye.
