Will technology and Universal Health Coverage prompt for-profits to try and bring affordable primary care to the uninsured mass markets, a sector those seeking returns routinely ignore?

As subscribers can read more about this week, Cephas Chikanda of Pulse Health in South Africa has spent four years developing affordable care clinics targeting the urban uninsured but cash-ready. But reaching profitability at its now-breaking-even Johannesburg pilot clinic has been an uphill struggle when you compete with free public services and not everyone sees your value proposition.

Universal Health Coverage may be the answer to sustainability but Chikanda is not holding his breath. Grouping accredited private providers with public and guaranteeing free-at-use or affordable access would help to bridge the primary care gap, and presumably bring in the kinds of guaranteed volumes to attract the private sector, but those countries in most need also lack the governmental infrastructure to enact reform successfully. And in federalised countries the payment landscape can diverge, one UAE hospital operator telling HBI that providing care for low-income patients is easier in Abu Dhabi than Dubai because its insurance system’s lowest rung is far more generous.

The routes into such mass markets are in principle straightforward, as some have told us. You might be the first for-profit to enter, revamping underutilised infrastructure can cost peanuts and in densely populated regions you are pretty much guaranteed volumes. But corruption and safety issues loom large while non-profits can sometimes provide stiff competition. US rural non-profit health system Sanford Health is the only international group we know of to enter primary care in sub-Saharan Africa.

Telehealth can be a route in but the financial models rarely stand upright unaided. Symptom checker Ada needed the support of the Bill & Melinda Gates Foundation to move into East Africa, South African app Hello Doctor’s founder talked about difficulties in coming up with a model for its telephone consultation pilots low-income community clinics, and whether Babylon’s Babyl – through which it provides a globally-unmatched 37% of all primary care in Rwanda, 5x more than Europe’s best-performer – has made it any money is not clear.

We suspect tech and telehealth will move things more quickly than governments and it is for the sake of billions that they do. You can have the world’s most wonderful tertiary hospitals but without proper primary care in the community millions will continue to suffer from easily-preventable communicable diseases and minor ailments, and quacks and healers will continue to fill the gap.