ARC held a webinar on the 17th of September to tackle the question of Private Sector engagement in Health Systems Strengthening in Africa. The specific focus of the webinar was, “As Africa grapples not only with the impact of COVID-19 on the health sector but with historical challenges, what role will private sector engagement play in health system strengthening?” The aim of this webinar was to start the discussion with critical stakeholders on the specific steps to be taken to achieve this collaboration at a practical level.
Bronwyn Timm, the Strategy and Partnerships Lead at ARC, moderated the event, which brought together a panel of experts from across the public and private sectors to discuss the challenges and opportunities for private sector engagement in African public health supply chains. The panel included Professor Richard Chivaka, Chief Executive Officer and Founder of Spark Health Africa, Dr Hudson Balidawa, a Public Health and Monitoring and Evaluation Specialist at the Ministry of Health in Uganda and Greg Badehorst, Managing Director from Imperial Managed Solutions.
To kick off the discussion, Professor Chivaka was asked to comment on challenges currently facing the African public health sector. Chivaka suggested that the challenges fall into two broad categories: issues on supply side and internal inefficiencies on the continent. On the supply side he highlighted that, the fact that most consumables are imported into the country makes for very long supply chains. This presents several challenges. Firstly, suppliers determine which markets are prioritised. “I think we saw this with COVID-19,” said Chivaka. “In most cases, unfortunately, African countries may not always be a priority, and as a result we don’t end up with what we need, and we end up with people who are suffering due to a lack of medicines.”
The fact that consumables need to be transported into the continent, either via air freight, which is expensive, or via shipping, which is slow, also complicates the costing and supply cycles. Once supplies arrive in the continent, there are other inefficiencies that come into play, from a lack of road infrastructure in some areas to ineffective warehousing and / or inventory management. Finally, there are political considerations and often a lack of funding or resources too.
In response, Dr Hudson Balidawa commented that, “I think one thing that is very obvious in our countries is that the health budgets have really not met the regional or global targets, so we are really limited in the first place.” He added that this makes it difficult to align with the SDGs. Public healthcare supply chains are not only complicated for noncommunicable diseases, but often don’t even include other, more neglected diseases. The poor tend to suffer disproportionately from the consequences of inefficient public healthcare supply systems. Other issues include corruption, monopolies in supply of certain healthcare consumables, and challenges in not only reaching the last mile but doing do effectively.
Timm asked Bonnie Fundafunda, Regional Lead for East and Southern Africa countries at ARC, to share ARC’s own definition of private sector engagement. Fundafunda said that ARC is trying to bring together the government and the private sector to create have a forum where both can begin to understand the challenges that are facing public health in terms of supply chain.
“I think there is poor understanding of the challenges that exist within the government sector in terms of applications of commitments of governments,” he said. “We are looking at strategies, we’re looking at policies. From the outside, looking into the dynamics of the public sector, you may think that things just never work in government because of all these processes. This forum aims to recognise there’s competence, within and outside the ministries of health.”
He added that the forum aims to achieve better understanding of the supply chain universe, so that common ground can be found that begins to shape awareness of and decisions that lead to creating better operational engagements with the private sector and to demystify the relationship between a government entity and the private sector. ARC hopes to see more patient-centred, productive, cost- effective, and competent service provision by the private sector to ministries of health.
Greg Badenhorst gave a private sector perspective. He explained that currently, tenders, along with ad-hoc engagements have been the most common platforms for private sector players to engage with governments, but that these also presented a barrier when it comes to private supply chain service offerings in the public space.
He noted that, “Ministries of health are also often funded by donors and engaging donor funds can be quite difficult if you are not already in the mix,” he said. However, he noted that engagements via ARC have been encouraging, which prompted his involvement in the webinar.
He said that private sector motives are often questioned, and the issue of trust remains a barrier, especially when it comes to patient focus. “There is a lot more focus on patients by the private sector than the public sector gives credit for,” he said. While communication channels have had previously existed between the sectors, more recently this has started to change, with donors and ministries of health reaching out to private sector players.
Chivaka believes that engagement will require a unifying agenda. While both have a direct stake in meeting healthcare objectives, Chivaka believes that the public sector often only turns to the private sector to address budgetary shortfalls. “It’s like a person who wants to get married because they can’t pay their rent,” he opined. “We need to want to get married because we’ve fallen in love, this is something we’ve planned, and it’s permanent – till death do us part.”
He pointed out that the private sector is not innocent either and it may be seen to prioritise profits above all else or to use public engagement for publicity or political ends. However, if partnerships are crafted in a way that recognises that a healthy society is beneficial for all, and to be patient-centred, they are more likely to be successful. Government has the power to establish infrastructure, which the private sector does not, while the private sector has technologies and systems that can benefit the public sector. Chivaka advocates for a marriage where both parties bring their strengths to the table to work towards a shared agenda.
Badenhorst encouraged governments to embrace private sector offerings, pointing out that not knowing what the flexible private sector has to offer is hampering genuine engagement. This may stem from a misconception that costs are inflated to meet profitability expectations. He believes there is also not emphasis on loss. “Expired stock is a massive challenge, but it’s coupled with shrinkage, damages and inventory accuracies,” he said. These losses far outweigh the costs of an effective and consistent supply chain.
While private businesses have invested in systems, resources and infrastructure to promote efficiency and visibility in the supply chain, the public sector is still grappling with the costs involved to do so. However, the more volume throughput, the more efficient these investments become and the cost at patient level improves dramatically.
Fundafunda noted that governments are at least asking the questions about how to engage the private sector, how services to patients can be modified to ensure that there is no gap in treatment, and how supply chain services can be improved and adapted, including leveraging the competencies of the private sector.
He believes these are great starting points, as this demonstrates that governments are awake to the idea that there is a role that private sector in its entirety, can have in public health and particularly in supply chain.
Balidawa agrees that the opportunities are enormous and says that COVID-19 has proven this through accelerating public and private sector partnerships and demonstrating the usefulness of technology, as well as highlighting gaps in healthcare systems that need to be addressed.
Badenhorst said that the webinar itself was a good example of public / private sector engagement and suggested that doors appear to be open on both sides. What is needed now is links to bridge the divide, which will require work from both sectors. This will require a leap of faith and building trust. There are examples of how it can work. “For example, in Ghana, the Central Medical Stores are managed by Imperial, and it’s a great example of a public private partnership,” said Badenhorst.
He encouraged donors to also play a part in challenging the public space and suggested that consideration also be given to using existing private distributor networks that are already well established to support the public service healthcare requirements. “We see this already working in the developed world and is something that should be considered, even if it’s as a hybrid model initially.”
Chivaka admitted that public sector supply chains can be inefficient and inflexible, and suggested that it’s for this reason that they should look to include the private sector as early as possible – to look at the characteristics of private sector supply chains that work well and to infuse these into public sector supply chains. “It doesn’t have to be defined as public sector or private sector,” he said. “It just for the country. It doesn’t matter who has contributed.”