PRIVATE HEALTHCARE IN EMERGING MARKETS An Investor’s Perspective IN THIS ISSUE: BUILDING UP TO BARCELONA ISSUE 4 | MAY 2017 2 Elena Sterlin, IFC Head for Health and Education, discusses preparations for the IFC Global Private Health Conference in page Barcelona, May 16-17, 2017. 3 CONFERENCE PREVIEW: CREATING VALUE IN HEALTH SYSTEMS page Charles Dalton, Senior Health Specialist, outlines the agenda for the IFC Global Private Health Conference. INTERVIEW: OPENING KEYNOTE SPEAKER 6 Dr. Elizabeth Teisberg, Professor at the Dell Medical School, University of Texas, Austin, discusses achieving value-based page healthcare in emerging markets. INTERVIEW: CLOSING KEYNOTE SPEAKER 8 Dr. Mark Britnell, Global Healthcare Practice Chairman and Senior Partner, KPMG, provides insights on universal page healthcare coverage. GUEST COLUMN 11 Johns Hopkins Medicine International highlights how enhancing the role of nurses in clinical care delivery extends page resources, standardizes outcomes, and reduces costs. CASE STUDIES, IFC NEWS & INITIATIVES 13 • • Recent IFC Investments Meet IFC’s New Health Economist • MedLife Case Study: Outpatient in its DNA page • Fybeca Case Study: Serving Low-Income Customers Elena Sterlin, IFC Head for BUILDING UP TO Health and Education BARCELONA A s we prepare to host our 7th Global Private Health Conference in Barcelona, I reflect on its remarkable We are expecting around evolution over the years. When IFC organized its first emerging markets health conference over a decade 500 participants from ago, there was debate over the legitimacy of private health services as part of the solution for growing all corners of the globe, healthcare needs in emerging markets. It was a modest affair, hosted in the IFC basement, with about 60 attendees—all IFC staff and 70 percent at executive clients—and an agenda focused on health services. level, with 60 countries It has been exciting for me to watch the conference grow into a major global event in the health industry, growth that has mirrored represented. increasing investment in emerging markets health. Milestones along the way include in 2010, the first time we opened up the conference to non-IFC clients and held it outside our headquarters in a nearby hotel. In 2013, we took the party beyond Washington to Istanbul. In 2015 in Prague, we expanded the agenda to include the pharmaceutical sector. Later this month, we will host our biggest conference to date. We are expecting around 500 participants from all corners of the globe, 70 percent at executive level, with representation from 60 countries. We are looking forward to helping them to network and share thoughts on how to create value-focused health systems, this year’s conference theme. As we cross the 10-year mark, I’d like to thank a few attendees who have been with us throughout the journey, including Hygeia, one of Nigeria’s largest integrated care providers; China-based United Family Healthcare, another integrated care provider; and Saudi German Hospital, which operates a network of hospitals across the Middle East. We all know the challenges in healthcare in emerging markets: lack of funding, shortfalls in health infrastructure, the rise of non- communicable diseases, and the aging of populations. At Barcelona, we aim to create the magic formula that inspires innovative ideas, ones where private and public sectors come together to find effective, integrated solutions to the problems we face. We hope this newsletter will serve as an appetizer to things to come. We have exclusive interviews with our keynote speakers Elizabeth Teisberg and Mark Britnell, newly published case studies from clients Medlife in Romania and Fybeca in Ecuador, and a guest column from conference lead sponsor, Johns Hopkins Medicine. We hope you enjoy! PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 2 CREATING VALUE IN HEALTH SYSTEMS—CONFERENCE PREVIEW I n 2015, the IFC Global Private Health conference was held in Prague where nearly 400 delegates At a time when there is an actively discussed the important long-term role the private health sector plays in emerging markets increasing global focus on how healthcare.  The 2017 conference will take discussions even further. With a greater number of delegates to build sustainable health registered and from a broader global geographical spread, the opportunity for active networking, sharing important systems, the core theme for the lessons learned, and developing long-term partnerships has grown. 2017 conference is value. In addition to fostering partnerships and investment opportunities, the 2017 event is built around relevant and pertinent themes where the private health sector has a voice.    At a time when there is an increasing global focus on how to build sustainable health systems and a deeper understanding of the role the private sector plays in many emerging markets, the core theme for the 2017 conference is value. We are fortunate that a leading figure in the value-based healthcare strategy movement will be the keynote speaker. Elizabeth Teisberg is Full Professor at the Dell Medical School at the University of Texas at Austin. Professor Teisberg, who is also a senior institute associate at Harvard’s Institute for Strategy and Competitiveness, centers her work on high-value care delivery and implementation of value-based strategy in healthcare by providers, employers, health plans, pharmaceutical and device companies, patient advocacy organizations, and policy makers. With her deep background in strategy and innovation and special attention to the healthcare sector, she collaborated with Michael Porter to co-author Redefining Health Care: Creating Value-Based Competition on Results (Harvard Business Review Press, 2006). PAGE 3 PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 Photo© World Bank: Checking vital signs. health dept., Bolu, Turkey To tie everything together, our closing keynote speaker is AN INVESTOR’S PERSPECTIVE—HEALTH PROVIDER Mark Britnell, the Global Head of Health for KPMG. Mark CASE STUDIES is Chairman and Partner of the Global Health Practice at KPMG. Investment insights and case study stories from private health entities with whom IFC has partnered. What have been the Since 2009, he has worked in over 60 countries, helping secrets of success? How to work with investors and keep governments and public and private sector organizations them happy? Key lessons learned and challenges faced. with operations, strategy and policy. He has a pioneering and inspiring global vision for healthcare in both the developed RIPE FOR DISRUPTION—THE FUTURE IS and developing world and has written extensively on what TECHNOLOGY works around the world including his first book, In Search of the Perfect Health System, published in October 2015. An engaging look at how medical technology and digital trends are changing the shape of health service delivery. What does this mean in emerging markets not only for Through a value-focused agenda, the private sector can investors looking closely at the Medtech space, but also for actively support the achievement of Universal Health those health service providers making medical technology Coverage through smart investment decisions and investment decisions? Which non-health industries may enter demonstrating smart business models that efficiently utilize the health market and cause disruption? resources and make use of appropriate emerging digital health and medical technologies. The conference will provide WHAT PATIENTS WANT: VALUE THROUGH QUALITY multiple insights into how success can be realized through smart investment strategies. A drill down into how a focus on quality benefits patient outcomes, experience, and overall care provision. The Key themes and panel discussions are summarized below: session will include case study examples of how quality not only adds value to the spectrum of care, but how it is feasible THE IMPACT OF SOCIAL AND PRIVATE HEALTH to implement sustainable quality management approaches INSURANCE that contribute to improved outcomes and at reduced cost. Social and private health insurance in emerging markets UNDERSTANDING REGULATORY AFFAIRS will expand significantly in the next decade. How will spending priorities be defined and how will this alter Using Africa and China as reference points, an interactive market dynamics? Will there be a shift from fee-for-service session to discuss the regulatory environment and approaches to bundled payments? What does this mean for private to improve the manufacturing as well as supply and providers of care and how can they provide insight and distribution of drugs and medical consumables in emerging support? How can we ensure that low-income quintiles can markets. What has worked? What are the challenges ahead? fully participate in these insurance systems? Which payment How is the regulatory environment developed over the years systems will evolve as most effective and efficient? Given and what are the strategies to manage the changes? How resource limitations, which services should remain out-of- to develop a better collaborative approach going forward? pocket and what should be covered by insurance? Specifically on pharmaceutical distribution, we will discuss the typology of countries looking to restructure their THE FUTURE OF MEDICAL DEVICES IN BRICS pharmaceutical supply chain, including for example—the Given the ever increasing demand for affordable health level of private sector involvement, regulations and upcoming services and the importance of timely access to health changes to the regulations, current level of fragmentation/ services, what are we learning and where is the medical concentration and trends toward consolidation, how the technology market heading in BRIC countries? use of technologies such as track and trace can be beneficial, PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 4 Photo©World Bank: Hospital Guatemala wholesale and retail mark-ups for medicines (by comparing prices across regions), sharing of drugs that are imported vs Learn more about the Conference domestically produced, and level of counterfeit drugs. at www.ifc.org/health-conference INNOVATIONS IN THE SUPPLY OF SKILLED HEALTH PERSONNEL Most emerging markets face uncertainty on how to train and retain health professionals. Using case study examples of innovative practice, this session outlines workable solutions for the training and development of health professionals in emerging markets. SUCCEEDING IN CHALLENGING MARKETS A ‘lessons learned’ dive by experienced emerging markets health sector investors and operators into some of the common challenges to be considered when making investment decisions in these markets. What are the common risks to be considered pre investment? What problems often arise post investment? How does the investment experience differ between younger and mature entity types? Does the health sector present specific issues? Are some markets facing a valuation bubble in the health sector? How to manage investment hype vs market reality. DISRUPTIVE MODELS IN PRIVATE AND PUBLIC COLLABORATION An interactive and provocative session to explore various models of public and private collaboration and how they support sustainable health systems and improve service delivery. Panelists together with active audience input will look beyond traditional infrastructure Public Private Partnership (PPP) models and explore emerging and expected future trends in public private collaboration. What are the lessons not to be repeated from previous PPPs? How can more conducive participative environments be established? How can the private sector play a direct and expanded role? For those of you coming to the conference, we look forward to seeing you in Barcelona. Stay tuned after the event for our conference eMagazine, where you can read summaries of all panel discussions and keynote speeches. Charles Dalton IFC Senior Health Specialist PAGE 5 PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 INTERVIEW: Dr. Elizabeth Teisberg ACHIEVING VALUE-BASED Professor, Dell Medical School, University of HEALTHCARE IN EMERGING Texas, Austin MARKETS Keynote Speaker, IFC Global Private Health Conference, Barcelona, May 16-17, 2017 Q: As the co-creator of the “value-based Parsimonious meaningful measure sets that are specific to health care” concept, are you heartened or different health segments will enable us to track success disillusioned with how markets have evolved and accelerate improvement. Measures that are overly since you published your book a decade ago? broad across all of healthcare will slow improvement by distancing specific efforts from what is measured. That said, Value for patients is now recognized as a critical goal sharing measures across organizations will speed shared in healthcare delivery. This raises aspirations to achieve learning. The International Consortium of Health Outcomes better outcomes for the money spent, and thus expands the Measurement is working to provide measure sets to enable opportunity to enable better health for more people. All of this learning.  that is heartening. Q: As an American based in the U.S., what is your Improving health outcomes is the goal of healthcare. take on its heated debates around health policy Spending reduction is necessary, but not sufficient. People —in particular, what lessons should the rest need appropriate, efficient, effective care. of the world draw from how the U.S. system is organized and from efforts to improve it? Politeness and respect are critical, but should be the norm, not the stretch goals. People don’t seek healthcare for The United States drives up spending by failing to provide the experience of treatment, but the experience should universal access to effective early stage and preventive care. nonetheless be caring and compassionate. This is a mistake to avoid. Every nation in the world with Improving value for patients—achieving better outcomes that some form of universal access to primary and preventive care are meaningful to patients and families, for the money spent has lower costs per capita than the U.S. does. over the full cycle of care—aligns the professional aspirations Unfortunately, with universal access only to emergency of clinicians with the goals of the individuals they serve. That rooms, the U.S. policy debates have had to remain focused alignment is an antidote to burnout. And this support for on access questions. It is important to solve and get beyond professionalism is also heartening. access issues to the questions on how to transform care delivery and achieve better health results. Countries with Q: universal access to early and preventive care can focus on What is the measure or measures of success in a transforming to high-value healthcare. healthcare market? Q: You will be joining us in Barcelona next month for our biannual conference on private health High value means improving the health outcomes achieved care in emerging markets. What parts of the for the money spent on the full cycle of care. Health is agenda are you most excited about and why? individual, though people share health circumstances. Organization around the shared health circumstances that There are myriad opportunities in emerging markets to many people face can enable the success of effective, kind, leapfrog current approaches and design effective, integrated efficient care for more people. To measure this success, the care that achieves high-value care delivery. Transformation is healthcare sector needs different outcome goals in different difficult for most people to imagine, but the possibilities are patient segments. For example, the outcomes that matter huge. Think back to your phone service in the days of wired are largely similar among patients with the combination land line phones. No one complained that their phone didn’t of hypertension and diabetes, and largely similar among take pictures of their children playing at the park—it was children with asthma, or among frail elderly adults, but beyond imagination. Healthcare delivery could change that outcomes are different for those three examples. much in the coming years. PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 6 Photo©World Bank: nurse vaccinates a child for polio - Beirut   Q: What are some innovative business models you are seeing emerge that take on board this notion of value-based health care? “ I hope the world will see more Organizations that start from understanding the needs of healthcare value achieved for individuals are creating exciting new models. Some provide “surround sound” support for lifestyle change, such as the more people. This requires new chronic headache care centers in Germany, which aim to improve exchange of information and coordination of transforming systems to treatment for better outcomes. Some organizations provide different approaches to communication that change the be about health, not just location, medium, or delivery of the message rather than just re-scripting what it said. treatment. ” Organizations that measure meaningful outcomes during and after care drive the insight to achieve better and better health outcomes for the people they serve. Usually, this involves creating interdisciplinary care teams that integrate the needed care rather than layering on coordinators in systems of fractured care.   Q: What are your predictions for how health systems and markets in the coming decade will evolve and what are the core challenges that need to be addressed? I hope the world will see more healthcare value achieved for more people. This requires transforming systems to be about health, not just treatment. Organizations rarely improve what they don’t measure. Measuring meaningful health outcomes is a powerful lever for driving the needed transformation. PAGE 7 PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 UNIVERSAL HEALTH INTERVIEW: Dr. Mark Britnell, COVERAGE—ONE OF THIS Global Healthcare Practice CENTURY’S GREATEST Chairman and Senior Partner, KPMG CHALLENGES Closing Keynote Speaker, IFC Global Private Health Conference, Barcelona, May 16-17, 2017 Q: What inspired you to write your book, ‘In Search of the Perfect Health System’? Over the past eight years, I’ve had the privilege of working in 69 countries on over 300 occasions, and worked with a wide variety of public and private organizations. This has provided me with a unique opportunity to look closely at the strengths and weaknesses of health systems around the world. Over time, I’ve collected notes and ideas on my journeys. I wrote my book based on these experiences so that politicians, health professionals, patients, and the public can better understand that every country is facing pressures with their health service. Q: How attainable is Universal Healthcare Coverage (UHC) for all countries? The momentum behind UHC as a global priority is now unstoppable. Countries are increasingly appreciating that it provides not just a moral and social benefit, but also an economic and political advantage. These latter points are important, as politicians realize that investment in healthcare for all is a value and not just a cost. It has been estimated that a one-year increase in life expectancy can increase GDP per capita by 4 percent. The recent Lancet Commission noted that reductions in mortality in low and middle-income countries accounted for approximately 11 percent of recent economic growth. Given the ways in which healthcare has a direct gain on a country’s GDP, new global health funding streams have increased dramatically and remain an almost uniquely favored area of interest for international donors. KPMG’s new Center for UHC exists to help countries overcome these issues. We have developed an unmatched suite of tools, intelligence, insights, and experience to make UHC reforms a success. PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 hoto©World Bank: a nurse in the health center, .Athiémé, Near Cotonou Q: What are the key ingredients to implementing UHC successfully? How to achieve UHC will be one of this century’s greatest is in the midst of implementing the most significant national development program in over a generation. In the initial phase to be rolled out in May 2017, primary care physician services will be provided for free at point of care at approved challenges of political will and technical skill. Part of this providers across the public and private systems, as well as challenge stems from the lack of a clear threshold of when many drugs and diagnostics. UHC has been achieved, and how to measure progress toward it. Experience from the Millennium Development KPMG’s team has been working since February 2016 to Goals shows clearly that what gets measured matters, and support NHI Bahamas in a range of areas. We are helping the targets selected for health to draft guiding policies, define and programs have a major impact on cost the initial NHI benefits package, how those programs are designed. To date, only 60 of the world’s negotiate new physician fee schedules From our research on countries with options for capitated, bundled or that have achieved UHC emerge 192 countries are thought fee-for-service models, and establish three clear design elements that are an integrated governance structure to important to include. Firstly, some to have achieved universal direct the implementation of NHI and element of mandatory inclusion health system strengthening efforts. or membership in the scheme. coverage, leaving many of We are also assisting in procuring a Secondly, it is highly beneficial private operator to run the new public to pursue a ‘breadth then depth’ the rest with at best partial insurer (BahamaCare), designing the strategy, meaning you first try to IT architecture to support the scheme provide coverage to the entire coverage. and supporting procurement of the population for basic primary IT solution, developing relevant healthcare, and then expand this legislation and regulations, providing coverage to include more complex primary healthcare as health system strengthening support well as secondary and tertiary healthcare. Thirdly, include to bring public primary care clinics up to the required some form of public insurance or financing option, even if a standards, and facilitating stakeholder consultations with key private health insurance market is envisioned. constituencies. Q: What country provides a good lesson to share with others on UHC? Q: What are the common challenges in achieving UHC? To date, only 60 of the world’s 192 countries are thought to Our recent work in the Bahamas provides an excellent have achieved universal coverage, leaving many of the rest case study of wholescale transformation of a country’s with at best partial coverage that leaves them exposed to health system toward universal coverage. Several previous catastrophic healthcare costs. One common challenge will be attempts at introducing a unified National Health Insurance deciding how to deliver services given the global skills and (NHI) system, dating as far back as the early 1980s, had workforce shortages, which the World Health Organization been obstructed by political turbulence, vested interests in has estimated at 7.2 million health workers, rising to 13 the status quo, and implementation challenges. However, million by 2035. this cycle is finally being broken. After a renewed push by government—and with support from KPMG—the Bahamas PAGE 9 PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 Photo©World Bank: Hospital in Cambodia Other questions we have worked through with governments have demonstrated advantages and disadvantages to date. include—what is the role of the State? How will the system Single payers provide a large scope for raising resources and be regulated? What will the benefit package comprise? a potential administrative efficiency, but may lack choice and Who will be covered and for what? How will the system be innovation and introduce potential inefficiencies due to lack governed? How will the doctors be paid and managed? How of competition. A mixed multiple payer model can provide will the provision of care be monitored and evaluated? more individual choice and competition but can fragment care and increase complexity, while tending to escalate costs. Q: Private multi-payer models, such as through mandated What about spending—How do you get “better insurance with no ‘public option’, can help finance health value for money” when striving for UHC? services not funded publicly but can be associated with higher administrative and health system costs, and may tend UHC is about far more than spending more on healthcare— to create a less equitable and slower path to UHC. There is the design, performance, and equity of the system arguably not necessarily a clear “best practice” for funding healthcare have a much greater impact on progress than spending. and the funding approach choice should be based on the This is evidenced by low-spending nations such as Israel, needs, capabilities, and political situation of an individual Singapore, and Brazil that have nonetheless achieved UHC, country. and high-spending ones such as the United States and Russia Q: that have not. In many developing countries the instinct to replicate and imitate the health systems of developed Which parts of the Barcelona conference are you economies is strong, but new entrants are challenging such most excited about? thinking and introducing frugal innovation to meet local needs with better value. The Barcelona conference is a truly global event bringing together private and public sector healthcare players We recently convened a conference in Africa where more from around the world. I think it will be a great learning than 50 public and private sector health leaders from experience, with renowned thought leaders and innovators across the continent discussed the provision of low-cost, whose work and ideas influence our industry. I’m looking high-quality healthcare. Key aspects of frugal healthcare forward to a global exchange of ideas, knowledge, and best innovation included use of asset-light and fit-for-use facilities practices, and sharing the exciting work we are delivering that avoid over-specification, centralization of diagnostics through KPMG’s new Center for Universal Health Coverage. and support services and lean supply chains, and carer or supported services delivered in conjunction with patients and Dr. Mark Britnell is the author of ‘In Search of the Perfect Health families. System’ published by Palgrave (ISBN 9781137496614) and Global Q: Healthcare Practice Chairman and Senior Partner at KPMG. For further information, please visit the KPMG Center for Universal What are the basic options for funding UHC Health Coverage. and what are their pros and cons? Different countries have taken different approaches to paying for UHC systems and these can broadly be split into three groups: single, public payer; multiple payers including both public and private options; and multiple private payers. Each of these approaches has been used in multiple countries and PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 10 ADVANCING NURSES ADDRESSES GUEST COLUMN GLOBAL NEED Johns Hopkins Medicine International H ospitals in about half of the world’s nations are operating with subpar numbers of essential healthcare personnel. The World Health Organization recommends a Enhancing involvement of minimum ratio of 23 healthcare workers per 10,000 people, yet a global shortage nurses in clinical care delivery makes reaching this ratio a significant challenge—and a barrier to better patient outcomes. extends resources, standardizes The overall shortage is exacerbated when aspiring doctors from countries without robust academic centers pursue their outcomes, and reduces costs. medical studies in the United States, Canada, Australia or Europe—search of better economic opportunities. Johns Hopkins Medicine, a leading academic health system in the United States whose mission is to improve the health Overall, this model has helped reach patients in rural areas of the community and the world, helps to address this and improved the overall access to clinical care. shortage by enhancing nurses’ clinical skills and education SOLID RESULTS globally. In 1986, an analysis by the Office of Technology Assessment “In countries facing a lack of resources in healthcare delivery, (OTA) indicated that nurse practitioners can safely and nurses are a natural choice to increase those resources,” effectively provide more than 90 percent of pediatric primary says Mohan Chellappa, M.D., president of global ventures care and 75 percent of general primary care services. Since and executive vice president of Johns Hopkins Medicine then, multiple reports have confirmed these findings. International. “Hospital administrators are now seeing nurses as instrumental to augment capacity, standardize care, and “Specialized nurses provide care that is at least as good as reduce costs.” that provided by physicians,” says Chellappa, a surgeon by profession. “Nurses are the first line of contact with the THE CASE FOR NURSE PRACTITIONERS patients and therefore have the trust of the patients.” In the United States, one of the most successful capacity Patients’ trust—along with an increased use of technology extenders is nurse practitioners—nurses with the academic in healthcare diagnosis and delivery—helps nurses offer preparation (master’s or doctorate level) and training to the same quality of care as offered by physicians, in a diagnose and treat health conditions, while emphasizing standardized manner. disease prevention and health management. A GLOBALLY REPLICABLE CONCEPT “Nurse practitioner students enjoy the academic preparation, which builds upon their clinical backgrounds, allows them In many parts of the world, nurse training, education, and to develop in a specialty practice, and expands their skills in the practice environment have not yet evolved to the point pharmacology, pathophysiology, and physical assessment,” where advanced practice nurses can be developed and says Karen Haller, vice president of nursing and clinical incorporated. Addressing policy and licensing, access to affairs for Johns Hopkins Medicine International. education programs and the culture of how nursing roles are used and perceived is still needed to gain the benefits of using The American Association of Nurse Practitioners states that nursing to extend limited resources. there are more than 222,000 licensed nurse practitioners in the United States. Their clinical focus areas cover the range from primary care to acute care, and from pediatrics to gerontology, as governed by national and state-by-state laws. PAGE 11 PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 Photo© Johns Hopkins Medicine International For nearly 20 years, Johns Hopkins Medicine International D.N.P. students at Johns Hopkins Aramco Healthcare has collaborated with organizations around the world in the recently launched a palliative care nurse-led consultation public and private healthcare sectors to help address these service to standardize the process to foresee and address issues, including program development related to advancing the needs of patients at the end of life, including outpatient nursing practice that is customized to the local region. services and home health care follow-up. The consultation service is estimated to save over $2,500,000 a year in “There is a global demand to elevate nurses’ practice,” says admission costs—but the true value of the program is Haller, who holds a doctorate in nursing. “Depending on the reducing the pain and emotional suffering of patients and location, this is driven by the need to enhance quality and families. safety, become more cost-effective, or leverage physicians for more complex care.” THE ROAD AHEAD Between 2015 and 2016, some 300 nurses and nurse For decades, trained nurses have assisted with care, mainly leaders from nine countries participated in nurse leadership taking part in non-interventional clinical care delivery, such development sessions in Baltimore, USA, sponsored by as monitoring and recording vital signs. This approach Johns Hopkins Medicine International, the Johns Hopkins does not leverage their clinical training and fuels the notion University School of Nursing and the Institute for Johns among patients that doctors are the only ones with the Hopkins Nursing. Through interactive workshops, they knowledge to treat a condition and provide care. built skills ranging from establishing budgets to navigating difficult conversations with staff members. There remains a need to fully educate local communities— and physicians—in emerging nations to provide the evidence In Colombia, nurse leaders at Fundación Santa Fe de Bogotá that healthcare delivery requires a team approach between (FSFB) are building on the training they have received as part nurses and physicians. of a long-term collaboration with Johns Hopkins Medicine International. The development of a Department of Nursing, “Sometimes there is reluctance from physicians and patients a new nursing practice model and the creation of a chief to rely on nurses as care providers. But when they see the nursing officer position are among the successes. benefits—more access, longer visits, more empathy—they are more likely to adopt the system,” Chellappa says. “We’ve In the Kingdom of Saudi Arabia, Johns Hopkins Aramco seen it in the Kingdom of Saudi Arabia: The initial hesitancy Healthcare—a healthcare joint venture between Saudi from the patients and families now has been reversed.” Aramco, a world leader in energy, and Johns Hopkins Medicine—and the Johns Hopkins School of Nursing Physicians themselves can be a powerful ally in—and established the first Doctorate of Nursing Practice (D.N.P.) beneficiary of—paving the way for advancing nurse practice, program in the Kingdom as a way to address the local especially those who return to their home countries after physician shortage. training abroad and experiencing firsthand the advantages of working as part of a highly trained healthcare team. To earn a D.N.P.—the highest degree possible in the Content courtesy of Johns Hopkins Medicine International. The profession—students must complete two years of academic, content was reproduced with permission from Johns Hopkins clinical, management and leadership studies, culminating Medicine International Marketing and Communications. Additional in an independent project. The program enhances nurses’ reuse and reprinting is not allowed. The information aims to clinical skills, develops their leadership skills, and solidifies educate readers and is not a substitute for consultation with a physician. To learn more, visit hopkinsmedicine.org/international. their role as an essential complement to physicians in delivering healthcare. Photo above: A group of 13 Doctor of Nursing Practice program students visit the Johns Hopkins Hospital to fulfill part of their “This program is my dream,” says D.N.P. student Leena nurse leadership coursework. Also in the photo are Johns Hopkins Al-Mansour. “I want to improve my leadership skills and my Aramco Healthcare nurses, school of nursing instructors and Johns clinical practice. This is a golden opportunity.” Hopkins Medicine supporters of the program. PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 12 RECENT IFC INVESTMENTS SENIOR ASSIST/ACALIS (LATIN AMERICA AND GHG (GEORGIA) THE CARIBBEAN) IFC is investing in Seniority Chile S.A., a provider of A subsidiary of Bank of Georgia Holding, Georgia quality senior healthcare services in Latin America that Healthcare Group Holding (GHG) is the largest operates under the brand name of Acalis. The investment, healthcare company in the country, owning operating which is IFC’s first transaction in senior healthcare services, companies that are market leaders in health services, will support the creation of a network of professional- health insurance and pharmaceuticals retail and quality nursing homes in Chile and Colombia, responding distribution. IFC is supporting the expansion of Evex to the needs of the rapidly aging population in Latin Healthcare services, the largest chain of hospitals America. Acalis is part of the Belgian group Senior Assist country-wide, currently represented with 76 hospitals International, which operates nursing homes in Europe, Asia and clinics in six regions of Georgia serving patients and Latin America. from all segments of the population covered by Georgia’s universal health insurance scheme. The expansion financed by IFC includes the renovation MEDLIFE (ROMANIA) of two recently acquired referral hospitals, a major expansion of its ambulatory clinic network and diagnostic laboratories, potential acquisitions, and expansion of its services in existing hospitals. The company offers a host of integrated medical services to individuals and corporate clients, catering to the middle-income segment of the country’s population. This REGENCY HOSPITAL (INDIA) is IFC’s fourth transaction with company and will help to further increase the national coverage of its services through expansion into second- and third-tier cities and the broadening of its service offerings. A healthcare service provider which owns and operates a healthcare network in the Indian state of Uttar Pradesh. Regency’s network currently includes two AVERSI PHARMA (GEORGIA) tertiary care hospitals, a healthcare clinic providing outpatient and diagnostic services, and dialysis treatment centers operated under a joint venture with Fresenius Medical Care—the world’s largest provider A privately held group engaged in pharmaceutical of products and services to people with chronic kidney manufacturing, distribution and retail, healthcare services, failure. IFC is helping to finance the completion and and health insurance. It is one of the largest pharmaceutical opening of operations for a new oncology hospital, retailers and distributors in the country and it positions which will be Uttar Pradesh’s first oncology specialty itself as an affordable and convenient pharmacy for the care facility and operated under a joint venture with low- and middle- income population. IFC will finance the Healthcare Global Enterprises, also an IFC investee, as construction of an advanced oncology center in Tbilisi and well as a new secondary care hospital. IFC’s investment an outpatient clinic in Telavi, East Georgia. IFC will also will also support Regency’s planned expansion to support the acquisition of state-of-the-art medical equipment cities in Uttar Pradesh, which lack quality health for both clinics. Many of those services are scarce in Georgia, infrastructure. especially in the country’s outlying regions. PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 13 Photo©AHLL APOLLO SPECIALTY (INDIA) MEET IFC’S NEW HEALTH ECONOMIST Apollo Health & Lifestyle Limited (AHLL) is a subsidiary of Apollo Hospitals Enterprise Limited, a leading Indian M healthcare group and a longtime IFC client. AHLL runs a network of multispecialty clinics including diagnostic eet IFC’s New Health Economist, Andrew centers, maternity clinics, planned surgery formats, and Myburgh, who recently joined IFC as a diabetes management clinics. IFC, together with its Asset senior health economist. He is going to be Management Company (AMC), has invested in AHLL to working on a number of initiatives over the coming help finance the opening of nearly 1,000 medical facilities, year. Two of these are to help clients improve the laboratories and collection centers. The investment will quality of care they provide, and to help determine create over 4,000 new jobs across India for healthcare the important contribution that the private sector professionals, including doctors, nurses, and technicians. brings to several countries’ healthcare systems. Improving and sustaining the quality of UFH (CHINA) healthcare delivered is important for all healthcare organizations. Andrew is designing an advisory program to help organizations improve systems’ diagnostics, structures, and policies. The diagnostic Chindex is a major private healthcare company which will determine which areas are not performing provides premium quality healthcare services in China and effectively, and will inform the development of a operates under the newly incorporated Healthy Harmony “treatment plan.” The team will be available to through the operations of United Family Healthcare. IFC is help implement the plan through the provision again investing in Healthy Harmony, through United Family of ongoing support. This approach has helped Healthcare to support the construction of a greenfield 150- healthcare organizations achieve substantial bed general hospital in Guangzhou. improvements in the quality of care they provide, and Andrew is looking forward to helping IFC’s clients achieve the same. ESSEX BIO (CHINA) There is a growing recognition of the contribution that private healthcare organizations make to countries’ healthcare systems. That said, A research and development-driven pharmaceutical understanding the role that the private sector plays company and a leader in the development, production, has been held back by lack of analysis and data and sale of biopharmaceutical drugs for certain niche eye that could clarify, and quantify the role of the treatments in China. Its drugs are used in the treatment of surface wounds and a variety of eye diseases and are private sector. This is changing. New data sets are based on basic fibroblast growth factor technology. IFC becoming available on countries’ disease burden is supporting the company’s plans to continue investing and the provision of services by the private sector. in research and development, increase its sales-force, and Using this data, Andrew will be working to provide improve its working capital management. more clarity on the role of the private sector and provide advice on how governments can work more effectively with the private sector to further strengthen the contribution of the private sector. PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 14 MEDLIFE CASE STUDY: OUTPATIENT IN ITS DNA “ A ll of a sudden, Aneliss rolled her for them given the complicated nature of the surgery. The eyes to one side, as if she didn’t medical team inserted metallic spirals (coils) that corrected know where she was, and began to the aberrant communication of the vessels at the site of vomit. She started to cry and then fistula and a resin consolidated the entire structure, allowing went into a strange state, she was the blood to resume its normal flow. just staring aimlessly,” explained her mother, Diana U. Her frail daughter, The surgery, which was done in September 2016, was a just barely 13 months old, went on to have a seizure. Her success. It was the first of its kind in Romania and Aneliss’ mother had suspected that something was not right with case was the seventh in the world to be treated with modern her daughter since she was born. Early on, she had bags techniques since 2010. Aneliss woke up without any under her eyes and when she was nine months old, small complications, was much livelier than prior to the surgery, veins appeared above the bridge of her nose and her eyes and had a big appetite. Reflecting on the experience, Diana had swollen significantly. Blood tests did not reveal any said, “We found a team of consummate professionals at particular issue but her mother was worried that the veins MedLife, who helped my daughter become a normal child. might burst, so they were very careful when handling her. She is laughing again and wants to get up and walk—she had started to walk right before her first seizure. I’m happy and The parents had planned on taking Aneliss to be seen in can’t wait to take her home! We are forever thankful to the Bucharest, where there is better quality care, but after this people at MedLife!” seizure they called 112 and took her to the emergency room in Constanta. A CT scan showed that there was a Twenty years ago, such a complex surgery would not have brain hemorrhage which could not be treated locally. The been possible in Romania. Mr. Mihai Marcu, Chairman neurosurgeon referred them to a public hospital in Bucharest. of the MedLife Board, explains, “MedLife was able to At 4:00 a.m., they arrived and the doctor told them to “enjoy successfully address this case because of the high level it while it lasts; we don’t know what could happen later.” of quality of our medical team and the state-of-the-art Those words were very jarring to the parents, and the mother technology in which we are always investing in. This responded by saying, “Doctor, I have no intention to bury my positions us to manage an increasing number of high child.” That doctor ultimately referred them to Dr. Stefanita complexity interventions, which are comparable to the Dima at MedLife. procedures performed in high-ranking hospitals abroad.” In addition to the MRIs and CT scans that had been done, MedLife, S.A. is the leading private, for-profit healthcare Dr. Dima ordered an angiogram, which provided a very clear provider in Romania, serving over 2 million patients annually view of what was happening. Dr. Dima told the parents that with 3,300 employees, of which nearly 2,000 are doctors they were dealing with a very rare condition—pial para- and 1,000 are nurses. MedLife has achieved such market galenic arteriovenous fistula—a type of venous aneurysm, penetration by offering “a one-stop shop” approach for which compressed the nerves and reversed the blood flow. patients through a network that integrates 37 outpatient This caused the epileptic seizures and the eyes to bulge. This clinics, 8 hospitals, 3-day care units, 26 laboratories with was the first case in Romania and there had only been six 143 sample collection points, 10 pharmacies, and 8 dental such cases in the world. clinics. Its corporate subscriptions, pre-paid employer provided healthcare packages for employees, have reached Anelis needed brain surgery. The father cried for two days over 500,000 individuals. Most of its patients are seen on an in a row fearing that they would lose their little girl, but outpatient basis. the mother told him she did not accept that—whatever happened, she must live. It was an emotional roller coaster PAGE 15 PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 Photo© @ MedLife In 20 years, MedLife dramatically elevated the availability TOP 3 SUCCESS FACTORS of quality healthcare, bringing it out of a communist era mentality and infrastructure and putting its services on par Becoming the largest private healthcare provider in with several of its European neighbors. It has demonstrated Romania was made possible in large measure because of that the private sector can be trusted to provide effective its hyperclinics, its focus on the patient experience, and its medical solutions. MedLife has become the leading pioneering attitude. healthcare provider in Romania by offering innovative, effective, affordable, and good quality healthcare. HYPERCLINICS The company has established a geographic footprint in about MedLife introduced the “hyperclinic” concept to the half of Romania and it has reached 80 percent of inhabitants Romanian market. A hyperclinic is a very large clinic that in the areas where MedLife has a presence. Over a period of treats a number of medical issues on an outpatient basis. 20 years, it has provided medical services to over 5 million This concept was revolutionary in Romania at that time. unique patients—this accounts for about 25 percent of the Romanians had believed that the hospital was the only place overall Romanian population. It is quite rare for a single to get problems solved, because communist medical systems private health service company to have treated such a large were typically hospital-centric.   share of the country’s population. In addition, 70 percent of its patients are women. The hyperclinic brings together a number of medical specialties under one roof and compliments high medical IFC played an important role in MedLife’s growth and quality with state-of-the-art diagnostic and treatment expansion through different stages of its development. In equipment, labs and pharmacies. With its “one-stop shop” 2005, IFC took an equity stake in the company with a $5 model, MedLife helped change the culture in Romania million investment and a EUR 5 million ($6.23 million) loan. toward a greater acceptance of medical solutions that can be This was later followed by two separate loans over the next done on an outpatient basis. The hyperclinic is the gateway decade totaling EUR 20 million ($24.3 million) from IFC’s and referral coordination hub for its other health services. own account. In addition, in 2011, IFC mobilized a EUR 40 million ($55.6 million) syndicated loan. In December 2016, PATIENT EXPERIENCE IFC supported MedLife in going public. It was the first healthcare company to be successfully listed on the Bucharest MedLife fosters a medical culture that is focused on the best Stock Exchange. In 13 years, the company’s revenues have care experience for the patient. For many Romanians, this skyrocketed. In 2003, the company’s revenues were $1.5 begins through employer-based corporate subscriptions that million and as of December 2016, they rose to an estimated provide access to MedLife doctors for annual exams and EUR 116 million, ($128.3 million). basic care. If issues are identified, care is escalated to the next tier, typically an outpatient clinic. Across its network, PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 16 Read the full case study at www.ifc.org/health Photo© MedLife it improved the patient experience by standardizing care and covering a large number of specialties—ten of which are specialized niches.2 Twenty years ago, the brain It attracts qualified doctors and is constantly increasing surgery that saved Aneliss’ life capabilities. It provides a clean medical environment and has a very low infection rate. It eliminated the “grey envelope,” would not have been possible in a widespread practice in public hospitals where patients are expected to make informal payments to doctors prior Romania but MedLife successfully to receiving treatment. It eliminated this practice by hiring doctors directly and paying them well. Unlike at public cured the little girl’s rare condition. institutions, everything the patient needs for treatment is provided by MedLife on site, without the need for the patient to provide medications and medical consumables in order to be treated. It has gained patient trust in a country grappling with corruption and has built a strong brand based on its good reputation. PIONEERING ATTITUDE MedLife was convinced that they could do better than the status quo in the post-communist era and they introduced a number of firsts in Romania. They were the first to introduce the hyperclinic concept, the first to offer a fully integrated solution for patients on site, the first to open a private hospital for Romanians, not just expatriates, the first to hire their own doctors as employees, the first to offer transparency in pricing for patients, the first to introduce the day surgery model in Romania, and the first healthcare company to successfully publically list on the Bucharest Stock Exchange. While some of these features may have already existed in other parts of the world, MedLife was the first to introduce them to the Romanian market and did so successfully. These efforts helped to change the culture of healthcare in the country. It shattered stereotypes and redefined patient expectations. It proved that the private sector has the power to safely resolve medical problems from the simple to the complex—with quality care. Ann Casanova IFC Health and Education Consultant PAGE 17 PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 Read the full case study at www.ifc.org/health FYBECA CASE STUDY: ACHIEVING SUSTAINABLE GROWTH BY SERVING LOW-INCOME CUSTOMERS T he mid-1990s were a challenging time for low- income Ecuadorians that needed to access Fybeca saw an opportunity affordable, quality medicines. Because of political turmoil and a severe financial crisis, urban poverty to complement its high-end increased from 35 percent to 65 percent between 1998 and mid-1999 in Ecuador. The lack of pharmacy chain with a down universal public insurance meant that private spending on health was almost entirely out-of-pocket, with an estimated 61 percent market chain so that customers on pharmaceuticals. could access quality medicines Both the rural and urban poor were equally impacted by the crisis. At the time, about 45 percent of Ecuador’s population resided in at economical prices. rural areas.3 The rural poor had limited or no access to public health facilities and experienced medicine shortages because pharmacies were concentrated in cities with high population densities. Instead they turned to traditional healers, travelled great distances to purchase medicines they could barely afford, or went without medicines. In cities, pharmacies were plentiful, but they catered to middle and high-income customers, neglecting the urban poor. Against this backdrop, Corporación Grupo Fybeca S.A. (GPF), a pharmaceutical retailer with a history of innovation, saw an opportunity to complement its high-end pharmacy chain, Fybeca, with a down market chain so that customers could access quality medicines at economical prices. In 2000, GPF launched SanaSana—its first pharmacy for low-income customers. GPF is a private holding company that dates back to 1930 with third and fourth generation family members still involved in management. The company employs 4,500 people and is committed to promoting gender equality — 65 percent of its staff are women— and the values of trust, transparency, and a desire to serve others. Today, there are 510 SanaSana pharmacies across 120 cities and towns in all 24 of Ecuador’s provinces. Around 218 SanaSana pharmacies are located in rural areas, smaller cities, and towns. SanaSana is now the country’s largest pharmaceutical chain of company-owned and managed stores and the second largest in market share. The brand has become prominent for selling prescription and non-prescription medicines, personal care products, general merchandise, and mobile phone airtime along with handling utility bill payments. In 2016, SanaSana pharmacies contributed to more than 50 percent of GPF’s revenues. Piya Baptista Inclusive Business Consultant PRIVATE HEALTHCARE IN EMERGING MARKETS: An Investor’s Perspective | Issue 4| MAY 2017 PAGE 18 PRIVATE HEALTHCARE IN EMERGING MARKETS An Investor’s Perspective ISSUE 4 | MAY 2017 IFC’S GLOBAL HEALTH TEAM Elena Sterlin Charles William Dalton Global Manager Senior Health Specialist Health and Education Head cdalton@ifc.org esterlin@ifc.org Biju Mohandas Chris McCahan Principal Investment Officer Chief Investment Officer & Medical Technology Lead & Global Health Lead bmohandas@ifc.org cmccahan@ifc.org Andrew Myburgh Srividya Jagannathan Senior Health Economist Senior Investment Officer amyburgh@ifc.org & Life Sciences Lead sjagannathan1@ifc.org IFC NEWSLETTER CONTRIBUTORS: Charles William Dalton, Chris McCahan, Elizabeth Price, Brian Beary, Ann Casanova, Piya Baptista, Andrew Myburgh, Irina Sarchenko Leticia Crentsil STAY CONNECTED Web: www.ifc.org/health LinkedIn: www.linkedin.com/company/ifc-health Twitter: #ifchealth JOIN DISCUSSION LinkedIn Group on Private Health in Emerging Markets hosted by IFC www.linkedin.com/groups/8429146 QUESTIONS? Please contact Newsletter Editor/Designer: Leticia Crentsil at lcrentsil@ifc.org