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Medical Credit Fund
Report: Beyond Investment: The Power of Capacity-Building Support
The Medical Credit Fund (MCF), a nonprofit impact investment fund within the PharmAccess Group, provides loans in partnership with local financial institutions primarily to private health clinics and pharmacies across sub-Saharan Africa.
Background
The Medical Credit Fund (MCF), a nonprofit impact investment fund within the PharmAccess Group, provides loans in partnership with local financial institutions primarily to private health clinics and pharmacies across sub-Saharan Africa. MCF seeks to improve the quality of the services its borrowers provide and to increase access to quality healthcare services throughout the region. To advance these goals, MCF offers both pre- and post-investment capacity-building support to its borrowers, as well as support to banks with which it co-invests.
Capacity-Building Objectives
MCF’s capacity-building support is designed to improve the quality of the healthcare services investee clinics provide and strengthen their businesses, which at the same time reduces MCF’s portfolio risk.
Other examples of MCF’s capacity building include the development of medium- and longterm strategy, preparation of business plans and financial projections, market assessments to identify growth opportunities, and planning the expansion or renovation of clinics.
Sample Capacity-Building Project Goals
| Increase Service Quality | Example goal: To improve a clinic’s infection-control and waste-management procedures |
| Strengthen the Business | Example goal: To improve client’s understanding of cash flow management |
| Support Co-Investors* | Example goal: To learn how to evaluate the creditworthiness and investment needs of healthcare providers
* Provided only to co-investing banks |
How it Works
STEP ONE: IDENTIFY CAPACITY-BUILDING OPPORTUNITIES
During due diligence, the PharmAccess team conducts a baseline SafeCare assessment, which reviews a number of key topics related to the quality of care in a healthcare facility, including healthcare organization management, patient care, specialized services, and ancillary services.7 This assessment identifies priority areas for improvement and investment. In parallel, MCF assesses the creditworthiness of the prospective client and the viability of the investment. During this process, MCF staff identify any issue that might merit capacity-building support. Often, opportunities to strengthen the quality of clients’ services are identified via the SafeCare assessments, while issues related to business strategy or operations are identified through other elements of due diligence.
STEP TWO: DESIGN A CAPACITY-BUILDING PROJECT
MCF uses distinct methods to define the trajectory of each type of capacity-building support.
- For healthcare providers, PharmAccess prepares a Quality Improvement Plan using the baseline SafeCare assessment. The plan lists priority actions to resolve any identified quality issues, such as training of staff or implementation of clinical guidelines, among others. The plan guides subsequent capacity-building support and monitoring of the quality improvement program.
- Smaller loan clients receive standardized capacity-building support with elements related to both the quality of the healthcare provided and business management.
- For larger loan clients (with loans equivalent to USD 200,000 or more), capacity building may include specific support in addition to the quality improvement program. MCF staff determine the need for and design these support activities either pre-investment or at the time of loan approval, consulting clients during project design and prior to implementation to gauge reactions and ensure sufficient buy-in. At times in these discussions, borrowers may express hesitations to engage in a given support program, but MCF may include provisions requiring the completion of such programs for loan renewal.
- When offering support to co-investing banks, MCF’s in-house investment management team works alongside the bank’s staff to help them understand the business of healthcare. MCF also provides regular training to bank employees concerning the specifics of the healthcare sector.
STEP THREE: IMPLEMENT THE CAPACITY-BUILDING PROJECT
The MCF team, the PharmAccess Foundation, and other technical assistance partners implement capacity-building programs related to both service quality and business strengthening. Partners include a range of organizations, such as associations of healthcare providers, and are selected based on their sector expertise and experience in quality assurance or business strengthening.
The healthcare provider then joins the SafeCare quality improvement program, which focuses on strengthening the investee’s underlying business, particularly in the areas of clinical quality and management capacity. The program is implemented by PharmAccess or its capacity-building partners, which have been trained and licensed to use the SafeCare standards and methodology. PharmAccess monitors the clinics’ progress on the agreed actions quarterly, repeating the SafeCare assessment every other year.
In addition, the MCF team provides pre-investment capacity-building support related to strategic and financial planning, investment priorities, expansion or renovation plans, and procurement. For capacity-building projects that require specific expertise, MCF contracts external consultants. The team may identify additional post-investment support opportunities based on ongoing review of the Quality Improvement Plan, which may indicate either areas of ongoing weakness or changing needs as the borrower grows and matures.
MCF may also recommend that its clients facing common challenges attend group management training programs. To this end, MCF and PharmAccess, working with a business school in Kenya, have set up a Health Management Course its borrowers can attend. MCF has found that clinics and other medical facilities benefit from the peer-to-peer support and sharing of experiences with the quality improvement program that result from participating in these courses. To facilitate this, PharmAccess has created Whatsapp groups that enable participants to learn from each other, as well as from the SafeCare staff.
STEP FOUR: MONITOR AND ASSESS THE PROJECT
MCF monitors each clinic’s progress on the Quality Improvement Plan developed during the design phase. For example, a project to strengthen human resource management might be evaluated based on the development of key processes and policies for reviewing staff and the provision of ongoing staff training. A project designed to improve primary outpatient healthcare might be evaluated based on the quality of patient waiting areas, the routine and effective use of infection-prevention techniques, such as handwashing, or the use of standardized processes for triage and patient orientation. During project design, these indicators are tied to the gaps identified in the initial assessment. To evaluate the result of the program, clinics participate in follow-up SafeCare assessments every two years. In addition, MCF gathers information regarding more quantitative business indicators, such as the number of patient visits, the number of staff, and revenues.
Evidence of Success
According to MCF, 70% of loan clients improve their operational, strategic, or impact performance following capacity-building support, as measured using the SafeCare system.
Clinics’ business indicators also show improvement, according to the SafeCare assessments. For example, one clinic reported an increase in the number of patient visits per month from 595 to 2,079. On average, revenues of participating clinics increase by 11%.
Funding
The development of sustainable sources of funding for capacity-building support presents a challenge for MCF. Currently, MCF’s capacity-building and other technical assistance projects are primarily funded by external sources, but MCF is in the process of establishing a cost-sharing mechanism.
- External funding comes from public or private grants made by the Dutch government, donor organizations, and other private funders. While some funding sources offer long-term grants over multiple years, others offer funding tied strictly to certain projects or regions.
- MCF also uses cost-share structures to ensure investee buy-in and establish sustainable project funding. Smaller loan clients currently receive capacity building free of charge, but MCF is implementing a cost-share structure for larger loan clients. The specific portion of the capacity-building costs investees cover varies widely on a case-by-case basis. Convincing borrowers of the value of capacity-building projects and finding or building local expertise to implement these projects both present challenges. The group management training programs, however, have gained traction among and are also paid for by MCF’s loan clients.
Looking ahead, MCF seeks to expand its use of co-payment structures in an effort to move toward a more self-sustaining capacity-building program. It plans to incorporate a capacity-building fee into each loan as a percentage of the total amount. This fee will cover capacity-building costs for larger loans but is unlikely to cover all costs of support for clients with smaller loans.
