Interview with Anuschka Coovadia, CEO at Usizo Advisory
HBI talks to Anuschka Coovadia, CEO at South-Africa based advisory group Usizo Advisory, about payor-provider relationships in Africa and ongoing efforts to improve healthcare coverage.
HBI: Tell us about your business.
Anuschka Coovadia (AC): We run a healthcare advisory practice predominantly doing strategy. Our business model is pretty similar to most consultancy firms – the only difference is that we are obviously much smaller, everybody on all our projects is always different, and we are generally a collection of subject matter experts. Clients I work for include government employee medical schemes and the International Finance Corporation. We tend to have longer, more hands-on relationships with our clients because if it’s successful, we usually stay connected to organisations in perpetuity.
HBI: You spoke on a panel at the IFC conference in Cape Town last month on tensions in the payor provider relationship relationship. What was your biggest takeaway from your conversations?
AC: There seems to be a far greater appetite for payors to understand the complex ecosystem that providers are working in. For me, that’s something new because before Covid, it was often a very one-sided relationship. The payers have a lot more power than the average providers in our ecosystem and to date there’s been very little data sharing, co-creation of clinical pathways and mutual input into payment models. There hasn’t been much of an understanding of the different operational models that providers have and why they may not be conducive to certain payment pathways of payment models. But I did get the sense that there is a mutual understanding that we need to start looking at a lot of these models and systems if we want to be able to expand our services to a larger demographic and more diverse population.
HBI: Another theme that came up was the brain drain out of emerging markets, particularly from Africa to Europe. What can the private sector do to incentivise people to stay?
AC: We really need to work on fixing the ecosystem. It’s a very harsh environment and it starts at the point of entry into university. If you look at the school system in South Africa, the independent school sector produces outstanding students but unfortunately the university system just doesn’t have the capacity to absorb these students into the health STEM sciences and there are simply not enough positions for them to train as doctors, scientists, technologists, etc. So we’re losing a lot of our best and our brightest at that point during the actual training system.
We also have a lot of leakage out of the system because a lot of the students that gain entry do not have the wrap around support that they would require to make it through those difficult college years. There’s a lack of financing, there’s a lack of support, there’s a lack of mentorship and there’s a lack of digital enablement in many of our curriculums which are really lagging very very far behind. Then when young graduates qualify, they can’t get access to internships. And there’s a lack of funding for specialty posts. Currently, all healthcare education is provided by the public sector so there’s no private sector provision of specialist training or medical training for any health sciences positions.
The actual clinical environment in our public sector has a lack of equipment and medication. Infrastructure is old and outdated, there’s a lack of funding and mentorship support. It’s a very, very difficult and long path for a lot of our healthcare workers and they all are always very remorseful when they have to leave our country because of the type of experience and exposure and impact you can have in South Africa. A lot of them feel very frustrated when they move to the UK, and they really are limited in terms of this scope of practice. Unfortunately the circumstances are often so harsh here that they’ve got no choice and are forced to emigrate.
HBI: What can the private sector do to address that?
AC: I firmly believe that we should not create a healthcare apartheid in our country and we should make sure that we allow for access to healthcare education for children and students from all types of economic and social backgrounds. But I do think we are missing the presence, scale, skill, and the capacity of the private sector in the healthcare education space. The game changer for South Africa will be for us to create a really successful public-private partnership where we’re able to take healthcare education into the next century and modernize the way we train our students.
We have some of the best in the brightest clinicians in the world but we’re not giving them the tools and the environment to work in which allows them to work to the best of their ability. We really need to understand how we can tap into the resources and efforts of both the public and private sector and create more health care opportunities for students. Find ways of keeping them in our country by improving working conditions, access to training positions, paying them better, and making sure that they are treated in a more humane, caring, and empathetic manner. Any health care worker that goes through training really has to be very resilient to survive some of the hardships that they have to face and I don’t think we should be continuing this type of treatment.
They really are such a treasured resource and we know from Covid that many of them go above and beyond on a daily basis to serve under such extreme circumstances. Unfortunately you know there’s very little recognition, support or acknowledgment for the hardships they endure. It’s really sad because they don’t want to leave the country. They love it here and they want to serve and they’re so passionate, but it’s almost like they’re just burning out.
HBI: How much uptake of digital solutions is there in the markets that you’re focused on?
AC: I just did a study for the IFC where we identified more than 400 digital health innovators in South Africa alone. There’s a huge explosion of digital health solutions that are being designed by people who work on the frontier of healthcare because they’re finding gaps in the current service provision and creating digital solutions to address those gaps. Many of them face huge obstacles when it comes to making their models commercially viable and scaling their models. That’s where we often see a lot of these amazing innovators and innovations just fall by the wayside because they simply can’t get themselves integrated in the healthcare ecosystem.
It’s almost like the barriers to entry are stifling innovation and we haven’t actually created a marketplace that is connecting the supply to the demand. We really are missing out on modernising our healthcare system because the solutions are local, they’re here and they’re amazing. We are just unable to tap into them in a way that actually allows us to benefit from the offerings that they’ve created. One of the examples is a healthcare app that I’ve done quite a bit of work for called Vula Mobile. It’s a free app that connects nurses and doctors and allows them to give healthcare advice for free. Because of market dynamics, these applications are not getting the scale that they require.
HBI: What is the main barrier to entry that stifles this kind of innovation?
AC: A lack of an effective marketplace which is allowing supply to match demand and actually embedding digital technologies into the clinical pathway in a manner that recognises the value. Right now, the actual clinical practice in South Africa and many African countries is probably 25 years behind the current advances from a technology perspective. So the practice of my generation is very similar to the practice of one or two generations before us. That’s because technology hasn’t invaded the clinical pathway. Some of that goes back to the way that healthcare is commissioned by the large payers and the fact that technology is not really commissioned as part of the clinical pathway and isn’t embedded in the current payment mechanism. We would hopefully see more consolidation and coordination in the provider space and hopefully that will lead to more of a multidisciplinary approach and a holistic life stage approach management to patients with technology as an enabler across those different pathways. But right now, it’s highly curative and mostly hospital-based and specialist-driven and there is very little continuity across the different points of access. There’s very little sharing of data, there’s very little coordination. Because of that, we have huge duplications and costs, a massive impact on the tiniest access to care and the patient experience is often quite a difficult one.
HBI: What proportion of people are actually using the private sector?
AC: About 16% of the country in South Africa uses the private sector and they are covered by medical schemes, but there’s a large group of patients that use the private sector who actually tap into out-of-pocket payment, which is really not a very good way of paying for healthcare services. Hopefully as we move into an environment with a large public health insurance, we will see that the market is going to start having a lot more connections on the payer and the provider side. Let’s hope that that drives better quality and greater connectivity both in the primary healthcare sector and the tertiary sectors.
HBI: How optimistic are you about national coverage?
AC: We’re in a very gray zone right now. We are all watching, waiting and hoping that we make progress, but right now we haven’t seen any real effective progress which is sad and unfortunate. There really could be massive benefits across both the private and public sector if we are able to create a collaborative approach to improving coverage for patients, whether they’re covered by private medical schemes or a national health insurance, or employer-based insurance. But unfortunately, at this point I really don’t feel like we’ve seen adequate progress on that front.
HBI: Is the lack of cooperation from the public sector hindering that?
AC: The economic situation in South Africa really makes it challenging to implement massive public insurance. The political situation is also quite divided, there’s a real lack of unity and focus on driving forward effective healthcare change. We’ve got a very deeply entrenched, highly sophisticated private sector that provides a fairly good quality of care. Any youth in the private sector will not be satisfied with being pushed onto a public sector that is not functioning up optimally. So there’s so many challenges and the overriding challenge is the current economic position of the country. Until we get ourselves into a place where we have sufficient economic growth to be able to fund the startup of effective public insurance, we’re in no man’s land. We’re in a pre-election year which means there’s a lot of political tension, social discord, and mistrust right now in the environment. We don’t have that focus, leadership and cohesion that will allow us to actually sit around the table and look at the assets of the public sector and how the private sector can be utilised for the benefit of the South African citizen.
We don’t see that conversation happening and we don’t see any implementation from that. Unfortunately healthcare is very much behind hidden doors right now and we’re just not seeing any progress. The average healthcare citizen in the country is really suffering and in the private sector, the affordability of medicaid has become a real challenge, particularly with the unemployment rate being as high as it is. So we’re not seeing growth in the private sector in the medical scheme market; in fact, we’re seeing lots of membership losses. In the public sector, we’re not seeing adequate levels of quality and access and service either.
HBI: Where does the most realistic untapped potential and opportunity lie that could deliver positive short-term results?
AC: We need to look at bringing in the next 16 to 20 million of the employed uninsured South Africans into the market. We will need to do this by reconfiguring provider models to be able to provide low-cost good, quality standardised care, scale, and backing that provision up with affordable accessible patients into health insurance or medical scheme products. That’s the biggest opportunity.
HBI: Which markets are you currently operating in?
AC: We’re based in South Africa but currently we’re running projects across Zambia, Tanzania, Uganda, and Kenya. Our clients need information. We’re busy with a large digital health project right now in those countries so it’s really very, very much tailored towards our clients needs.
HBI: Any plans for expansion beyond those territories at the moment?
AC: We’re quite comfortable to cover most African countries. Obviously, the countries where there are wars and conflicts are difficult to get access to but I think that we’d be very happy to do work in East Africa and North Africa. We don’t speak French, so that’s always a challenge and we don’t cover the francophone parts of Africa. Central Africa is a bit difficult to work in; it is difficult from an access point of view – and a conflict point of view.
We would welcome your thoughts on this story. Email your views to Michaila Byrne or call 0207 183 3779.
