by Michael Bernaski
We are grateful to share this thoughtful article written by Michael Bernaski, a valued supporter of African Mission Healthcare. Michael contributes not only financially but also through his time and expertise, consulting with AMH and several of our partner hospitals to support strategic planning and operational improvements that strengthen our impact.
Michael brings over two decades of experience in healthcare transformation, having served in senior leadership roles at PwC and Huron Consulting Group. He has advised some of the largest health systems in the U.S. on initiatives focused on performance improvement, care model innovation, and enterprise strategy. His insights have been instrumental in helping AMH and our partners think long-term about how to build enduring and improving health systems across Africa.
When it comes to philanthropy there are many ways and places to invest. Some needs speak to our hearts, and we are immediately comfortable writing a check. That is wonderful and Africa has plenty of appeal for our hearts. But the problems facing Africa are complex. The need for multi-year commitments and sustained attention abound. The returns on those investments can be extraordinary, but their complexity makes them risky.
The purpose of this white-paper is to make the case — whether you are an individual donor, estate planner, family office or a professional philanthropic organization — of why Africa is deserving of your investment. The needs and potential of the continent are vast.
Introduction
The natural and human resources of Africa are rich. It is estimated that 30% of the world’s mineral resources are in Africa and perhaps two-thirds of the world’s arable land. The population of Africa is over 1 billion people and unlike other areas of the globe the population is youthful. Birth rates are high, and longevity is increasing. By 2045 the population is projected to double.
While Africa represents perhaps 20% of the global population its collective gross domestic product is less than 3%. The people are poor by any standard, but economies and per capita GDP are slowly improving overall.
Africa suffers from weak institutions — public and private. As income grows its benefits will not reward everyone equally. As elsewhere, there is a tendency for those with more resources to benefit while those with less are not at the table to receive their share.
Investors that help build stronger institutions can generate a wonderful social return on investment, while ensuring better equity. But strengthening and building institutions is hard work.
Investors need to focus on both capacity building and utilization. They need to build on existing competencies and capabilities while also investing in generational improvements in education and healthcare. Investments need to facilitate the deployment of those amplified resources to productive and rewarding means.
The social return investor has important decisions to make. Direct investments are of course important. For truly sustainable change, strategic investments are also crucial. Those that require sustained attention and at times painful choices. To paraphrase the saying, giving a hungry person a fish feeds them for the day. Teaching them to fish feeds them for a lifetime.
Need and Potential
There is suffering around the globe but perhaps nowhere as widely felt as sub-Saharan Africa. What confronts a visitor is that a high degree of suffering and difficulty has been seemingly normalized by people. They have accepted it as a precondition of their lives. Walking miles with a jug of clean water on top their heads or riding on a *boda boda* (small motorcycle outfitted with an outsized seat) with a casket or large branch of bananas precariously tied across the back are familiar sites.
A visitor also sees a wonderful tapestry of smiles. Once suffering is expected, small things are allowed to give delight. There is hope and optimism. It is inspiring.
Family stability varies as elsewhere but there is plenty of evidence that strong nuclear families exist, often with the mother as keystone. Primary education and basic healthcare are far from universal. But Africa also has its entrepreneurs and socially minded citizens. Its natural beauty make tourism a large potential economic opportunity. Most employment is agricultural including animal husbandry. Men tending to their cattle or goats staked along the highway to graze are common sites. Produce is for sale regularly along the road. People barter for healthcare and schooling for their children.
The quantity of idle time people possess reflects their lack of gainful employment and self-improvement opportunities. A visitor sees and feels the potential. The natural resource is vast (including the highly contested rare earth minerals) but the underemployed human resource is perhaps the greatest potential. Africa deserves the opportunity to grow its human capital.
Investing in Institutions
In post-colonial times Africa has struggled with institution building. The public and private institutions are weak in general. Highly vulnerable to the self-dealing of leaders and susceptible to abrupt changes in direction. The planning capability (seeing past the horizon) is underdeveloped, and the coordination/integration of institutions has not been a priority.
Perhaps the greatest issue is the lack of trust in institutions. Generations of Africans have been let down by them. People are wary of global and national institutions from afar, in part because they have extracted more value from Africa than they have returned. But they are equally wary of domestic institutions that have also let them down. Legal rights of the individual are inconsistently defined and applied. To move forward the institutions need to be improved – some grown from whole cloth or reinvented — others strengthened. But as important, people need a reason to have at least some faith in institutions. That faith must be rewarded with results.
There is plenty of reason for social investors to be optimistic. There are examples of maturing institutions with the governance, information systems, human capital and financial awareness to be increasingly confident that they can endure while growing. And survive moderate disruption.
Direct and Indirect Investments
Much of the giving to Africa is additive. Direct resources like capital assets (e.g. buildings for healthcare, equipment for pre-mature births, ambulances for transport) or investments in time (e.g. medical professionals and teachers lending their services) are good examples. Direct inputs into the well-being of the people.
The reality though is that given the increasing population and magnitude of the need, higher leverage solutions are needed. Solutions that multiply the impact from each input. A great example is nursing education where hundreds of young people can learn the basic skills of caregiving and get on a pathway of continuous education. Or the use of predictive models to identify high risk mothers early in their pregnancy — preventive care and watchful practices can be efficiently employed.
Another healthcare example, medical doctors come from around the world to help give clinical care. Some for short stays, others for longer periods. Many missionary doctors come for life. Most often this benefits those suffering from acute conditions. The chronic disease burden in Africa, however, is substantial and under-addressed. Wellness and mental health have not been a priority.
Both direct resources and indirect investments are of course required. Additive solutions may stem the tide, but the best solutions are those that multiply the value of the inputs — building leverage in areas such as education and healthcare.
Capacity and Utilization
In Africa it is easy to assume that to be more profitable (in human and economic terms) investments in additional capacity is needed. Capacity is simply the ability to turn inputs into valued outputs efficiently and effectively at scale. How many outpatient visits can a hospital handle in a month? At what minimum standard of care? That is one view of the system’s capacity.
Most labor is manual in Africa. You see women heading to the fields with children tied to their backs, hoe in hand, to till the fields. People walk long distances as a matter of course. Regardless of the weather. Construction work is virtually all using basic hand tools.
The landscape of Africa is dotted with partially completed structures. And abandoned ones. No doubt some projects were started without the true costs being fully understood. Indeed, building even basic structures is non-trivial in much of Africa. Repeatability and the learning / predictability it encourages has not been a priority.
But sadly, a significant amount of the capacity constructed is underutilized. Or never utilized. While there is much need and what we might assume to be tremendous latent demand, working capital and discretionary income is a pre-requisite for the capacity to be productive.
Donor grants that are targeted at specific capital investments are well intended, but more responsible approaches try to increase the odds that working capital will be available to fund service delivery. Either because potential consumers have the incomes to pay a fair price, or because it is supplemented as part of the grant. At a minimum, at least enough working capital is needed initially to prime the pump and ensure at least minimal operative capacity. And that workers get paid on-time. Helping the local economy.
There is nothing worse than seeing very sick people who need care and knowing that there are empty beds in the hospitals. In highly developed economies, when demand outstrips supply, we anticipate private investments in additional capacity. Often overdone. Sometimes incentivized by government. An overcorrection settles back to a more optimal level after some time passes.
In Africa we must stimulate capacity building but also ensure it is utilized. That is far more complicated than writing a check and hoping for the best. It means entrusting your donations and grants to partners doing the hard work of institution building. They make sure that the capacity built is used at a minimum rate that justifies the investment.
Conclusion
There are geopolitical reasons to invest in Africa. Its natural resources continue to be highly valued and used around the globe. Worker shortages in the developed world can be addressed in part through immigration of African workers – as is happening in healthcare.
We cannot ignore the human implications of depriving Africa of those skills. The money expatriates send back to Africa is material, but many of these skills are needed locally. They must be gainfully employed.
Alleviating suffering in the short, medium and long term is also a great reason to invest in Africa. Suffering takes many forms. And while suffering exists across the globe, in Africa the basic graces of modern life are not yet available to the masses. While we hope and pray for a reduction of crises (natural or man-made) in Africa — the absence of crisis is insufficient. Relief is not investment either.
Perhaps the most compelling reason to invest in Africa is to unlock its enormous potential. First and foremost, for the benefit of the entirety of the population of Africa. But also for the world.