IIMA Empty text
BBOTSWANA HEALTHCARE
Empty tex
NOVEMBER 2019 ISSUE 4 Empty
Page of Contents Introduction
2
Botswana Healthcare Market
3
Understanding Investment Fundamentals in Healthcare
5
Millenial Doctors Trends
7
Supply Chain Management
9
BOMRA
13
ESG Insights
15
Alternative Medicine
17
Outlook
21
B o tsw a n a H e a l t h S e c t o r
360 Degrees Overhaul Post 53 years of independence Botswana continues to provide her citizens free healthcare and access to public health institutions and facilities. Many Batswana continue to enjoy free ARV treatment in the fight against HIV and AIDS and the quest to reach zero infections by 2030. Major strides have been achieved in the health sector with tangible results that can not be denied and credit to those that were at the heart of the transformation. However, public health continues to lag behind technological advances that could transform health care services and improve efficiency in patient care delivery and services for the young and old. Healthcare record management is still paper based with no repository to collate patient information and a central communication centre that links clinics to the main hospitals to improve communication and real time access to information by both patients and doctors.There continues to be duplication of efforts at every clinic and hospital in the collection of patient information. With the 4th Industrial revolution changing every facet of the old ways of doing business, the public sector is underway to experience eHealth which will reduce wastage, facilitate real time access to patient information and improve the supply chain.
I n t r o d u c t i o n | Pa g e 2
Healthcare Spending Early this year, P7.63 billion representing 16.2% of the National Budget was allocated to the Ministry of Health and Wellness. This was a slight increase of 1.2% from the prior year budget of P7.54 billion to the Ministry as more funding was needed towards the development and completion of the Sir Ketumile Masire Teaching Hospital during the year and change in reforms to establish Botswana as a health tourism hub with world class facilities, patient care and service delivery in the region. According to the latest statistics by the Visual Capitalist population health is a strong determinant in quality of life. As such, how much a country spends on healthcare as a percentage of gross domestic product (GDP) can be an important indicator. In comparison with Botswana, the U.S. spends 16.9% of GDP on its healthcare, nearly double the Organization for Economic Cooperation average of 8.8%. That is also over 4 percentage points (p.p.) above Switzerland, which ranks second with 12.2% healthcare spending by GDP (Visual Capitalist, 2019). Spending in health care will continue to skyrocket as more residents seek treatment locally and have access to internationally trained Specialists. The pharmaceutical industry is at an infancy stage with Multinationals dominating this sector. There are a few emerging local players who are stepping up to seize the untapped opportunities in the healthcare sector.
E m e r g i n g L o c a l M a r k e t | Pa g e 3
B o tsw a n a H e a l t h c a r e M a r k e t
Benefits Paid FY 2018 P250,000,000
P200,000,000
P150,000,000
P100,000,000
P50,000,000
Lindiwe Mafavuneh Founder & CEO LCM Capital
P0 Consultation Drugs and Rehabilitation Source: BOMAID
I have spent 13 years learning vicarously about the healthcare sector through my husband who is an Anesthesiologist and Managing Director of Mafavuneh Medical Services; the gruesome long hours, training and managing the Intensive Care Unit. I have also picked up a few medical jargon along the journey as a Finance Professional and enjoyed free consultation of having a Medical Specialist at home. Therefore, I am in a better position to compare and contrast the health care system of a developed country and that of a middle income country as we have had experience living in both economic societies. The factor that remains constant is the positive correlation between high spending in health care and good healthy living and high mortality rates of the residents and citizens of those countries. As Botswana gears towards elevating to a high income society, healthcare will be paramount as everything else stems from a healthy and productive human resource. Historically, healthcare in Botswana was dominated by the government with a few private players operating in this space.
Hospital
2018
Dental
2017
The introduction of medical aid in the 1990s resulted in the emergence of private healthcare providers that promised speedy service and thorough patient diagnosis compared to public healthcare. Botswana Medical Aid Society (BoMAid), is the largest open medical aid fund in Botswana with 51% market share and 39,000 principal members and 85,000 total lives. According to the audited 2018 financial statements P206,774,547 hospital medical benefits were paid compared to P179,334,565 representing a 15.30% increase in benefits towards hospital care. Second surge in benefits payments was on consultation drugs and rehabilitation with an increase of 11.61% and P171,737,590 (2017: P153,878,552) benefits paid. The year on year increase in benefits is consistent with the developments in the healthcare sector primarily the localization of patient care and treatment. Total Benefits paid in 2018
P552M
B o tsw a n a H e a l t h c a r e M a r k e t
E m e r g i n g L oc a l M a r k e t | Pa g e 4
70% In 2019 H1, 70% of the total amount raised from final closes originated from sector-specific funds
US$1.24B Total value of African PE fund Health Care raising in 2019 H1. Local health tourism will boost local healthcare manufacturing The local healthcare market is pretty much dependent on imports from other countries from the procurement of medicine and basic equipment including medical syringes. Due to lack of qualified and highly trained specialists, the government had over the years outsourced these services to neighbouring countries which came at a huge cost, the development of its own local facilities and infrastructure. The improvement of health facilities and change in reforms has attracted an exceptional breed of international highly specialized Botswana trained doctors to return to Botswana to develop the healthcare system. The return of specialists to Botswana will benefit the infant health sector to establish the health tourism which will help in the diversification of the economy. According the African Private Equity and Venture Capital Association (AVCA) 2019 H1 African Private Equity Data Tracker, which provides a provisional look at half-year private equity activity in Africa, Industrials, Consumer Staples and Healthcare were the top 3 sectors by value, accounting for 73% of the total deal value in 2019 H1. The report further outlines that healthcare showed an important increase in terms of volume and value, rising to 11% and 12% in 2019 H1 from 8% and 4% in 2018 H1, respectively.
Source: AVCA 2019 H1 Tracker Report
As the mining slump continues the need to find alternative ways to boost revenue is amplified. Healthcare enterprises are gradually making their mark on the local ecosystem. Most of the healthcare businesses are privately owned and managed by physicians. The country is yet to have a publicly listed healthcare company on the local stock exchange. Education-Healthcare business model has been the successful model that has seen the birth of Healthcare Entrepreneurs in Botswana. The renowned success story is the Boitekanelo Group which was founded by a Medical Doctor. The healthcare sector in Botswana is a blank canvas and an exciting sector for investors who enjoy being pioneers and front runners in order to reap the highest return on investment and a larger market share. Most healthcare service providers still use outdated equipment and technology which is bound to change as more players enter the market. To stay relevant, retain and attract patients, service providers will have to upgrade to sophisticated technology and equipment. The supply chain will have to include 4th industrial revolution technology like blockchain to improve transparency, tracking and delivery of medicine.
I n v es t i i n g i n H e a l t h c a r e
U n d e rs ta n d i n g I n v es t m e n t F u n d a m e n ta l s | Pa g e 5
UNDERSTANDING THE INVESTMENT FUNDAMENTALS OF LIFE SCIENCES AND HEALTHCARE By Alan Lok, CFA; Eunice Chu, ACCA; and Guruprasad Jambunathan, FRM
In the first part of this sector analysis published on Business Times dated April 27, we explored topical issues such as demographics, government policies and cost of drugs that can influence the performance of businesses operating in the life sciences and healthcare sector. Our analysis went on to touch on four elements affecting individual companies–level of demand, market structure, corporate performance, and track record–and environmental, social, and governance issues. In this second part, we will examine the different types of healthcare companies and provide suggested lines of enquiry to follow when considering a business for inclusion in an investment portfolio. As before, we will refer to life sciences and healthcare as the healthcare sector. THE MEDICAL CORPS We have divided the healthcare sector into three categories for ease of analysis. They are; i)drug producers ii)medical equipment and supplies manufacturers, and iii)health care providers. DRUG PRODUCERS Our desire to live is as strong as a drug company’s appetite for profits. We suggest that you initiate your assessment by examining the pipeline of drugs under development. In particular, focus on the various approvals that need to be obtained and establish how successful the firm has been in converting pipeline drugs into approved treatments. Keep a tab on costs as well. Nothing lasts forever. Inspect the company’s patent portfolio and the exclusivity period of its current drugs, especially the most profitable lines. Does the company have a strategy to deal with patent expirations and associated challenges? Consider the competition.What benefits do the company’s drugs offer above and beyond those sold by other groups?
Is the company aware of peers that have pipeline drugs in latestage development, which could well pose a threat to those currently being marketed or developed by itself? Consider the government of the day. Are there any regulatory developments that could affect the company’s ongoing business? Similarly, check if political or consumer headwinds might impact drug prices in the firm’s markets. In the United States, for example, there are proposals under consideration that would change the way drugs are priced in the Medicare system. Lastly, not all drug companies develop new products. Some specialise in the manufacture of generic treatments such as paracetamol. Therefore, your analysis should target specific areas of these businesses, such as the scale of operations,manufacturing practices, and the costs associated with introducing new drugs. Healthcare isn’t all about prescription drugs. We also use avast array of other treatments that are purchased over the counter. These include skin creams, lotions, and powders. Some are manufactured by the same companies that develop prescription drugs, while specialist firms make others. In this case, the brand is sometimes as crucial as the product itself. Think of baby powder, and Johnson & Johnson immediately comes to mind. Part of your research here should be to explore market share and name recognition. Do look at geographic reach and distribution methods in your research journey.
I n v es t i n g i n H e a l t h c a r e U n d e rs ta n d i n g I n v es t m e n t F u n d a m e n ta l s | Pa g e 6 Age demographics in a country matters in analyzing Asia is also experiencing rapid growth in healthcare healthcare companies. Are the products manufactured tourism, which is being underpinned by portable geared towards geriatric wards (body scanners or insurance policies, inexpensive travel, and greater mobility aids) or across all age groups (surgical awareness among consumers of the services available equipment)? With an ageing population across the out of their home territories. Bear this in mind when globe, there will be growth potential for businesses that examining a particular business and check out how manufacture equipment used primarily by the elderly. much income it generates from overseas patients. Does it have a strategy in place to develop this cash stream If we consider the medical supplies market, then this further? tends to be at the more consumable end of the chain– bandages, syringes, gloves, and swabs, for example. Determine the medical procedures that use these items:The more frequent the occurrence, the higher the potential sales. Similarly, it’s also worth your while to determine the disposable nature of these items. Single-use supplies have higher replacement levels. From a competition perspective, does the business dominate the market, or are others producing similar product offerings? Moreover, it helps if a firm has a long term contract with a medical facility or health board. If it does, determine the quality of this association and learn if Or are medical tourists in the region favouring Thailand it is reviewed periodically. over Singapore hospitals for certain procedures? Reputation is also vital. You will want to know if the HEALTHCARE PROVIDERS facility or company employs world-class professionals at The third category of the sector is occupied by the all levels and provides the best possible treatment. healthcare providers–hospitals, specialist facilities, Fortunately,for investors, this isn’t too difficult to check, hospices,and drop-in centres. This area is where health with hospital league tables freely available and review care budgets and population mix have significant sites awash with patient comments. influences over care providers. Ascertain the factors affecting healthcare spending in key markets and the Finally, take time to look at the health insurers and share of expenditure by different types of payers weigh up factors such as the medical loss ratio. This (government, insurance, individual out-of-pocket). measure gauges the amount of premium income Determine the dynamics governing demand from each. allocated to healthcare claims as opposed to Do also establish the availability and acceptance of administrative costs or profit. The Medical Care Act in alternative medical treatment centres. Ascertain the the United States requires many insurers to apportion a factors affecting healthcare spending in key markets and minimum of 80% of their income to claims. Now that the share of expenditure by different types of payers our examination is over, we hope you go on to lead (government, insurance, individual out-of-pocket). healthy and happy investing lives. For a more in-depth Determine the dynamics governing demand from each. assessment of the industry, our complete framework is Do also establish the availability and acceptance of available on www.arx.cfa. alternative medical treatment centres.
Healthcare Trends
H o w M i l l e n n i a l D oc t o rs a r e T ra n sf o r m i n g M e d i c i n e | Pa g e 7
By: Iman Ghosh- Visual Capitalist
Changing healthcare models, groundbreaking advancements in the health technology sector, and shifting standards of patient care—they are all contributing to a new era of medicine. But arguably one of the biggest changes will be the faces that greet us at a clinic or hospital. Today’s infographic from Public is Health illustrates the emerging generation of millennial doctors, and why they are on the cusp of transforming the healthcare industry.
The Changing Face of Medicine The doctor is in, but it’s probably not who you’re thinking of. Most people expect to see an older white male as their healthcare provider, yet today’s physicians are straying from this stereotype: Increasingly diverse 44% of U.S. medical school graduates in 2018 were of a racial minority background. i)Millennial women ii)61% of physicians under the age of 35 are females. iii)Digital-focused they are adept at practicing medicine with digital tools, like electronic health records and telemedicine. These younger doctors face intense financial pressure from student loans as they enter the workforce—an average of $190,000 to be precise—and it’s part of the reason that they’re more likely than their Generation X and Boomer counterparts to take jobs in hospital networks. Shifting practices are also altering interactions between these new doctors and their patients. As patients increasingly behave like consumers, they have to keep pace with their demands for shared decisionmaking and higher personalization.
Shifting practices are also altering interactions between these new doctors and their patients. As patients increasingly behave like consumers, they have to keep pace with their demands for shared decision-making and higher personalization. i)Millennial doctors spend over 8 hours a day on screens: 5 hours using electronic health records, and 3 hours more consulting external search websites. ii)37% of them also rely on social networks and message boards for work, compared to 25% of their peers aged 55 and above. The silver lining? These new doctors are digital natives first, which means they are comfortable using tools to help them practice medicine more efficiently than their predecessors.
Bridging Doctors
the
Gap
for
Millennial
The new profile of healthcare providers are seeing the lines between their work settings and everyday lives being increasingly blurred. When they don their “white coat” persona, millennial doctors are aware that they are always under the microscope. i)77% of patients rely on online reviews before choosing a physician. ii)80% of consumers trust online reviews alongside personal recommendations. iii)60% of consumers read four or more reviews before deciding on a doctor. As consumers themselves, millennial physicians are also constantly bombarded with content. They are active on social media during their “blue jeans” moments, allowing them to engage with patients even in their downtime. This entirely new environment propels their healthcare decisionmaking in radical ways.
 Healthcare Trends
H o w M i l l e n n i a l D oc t o rs a r e T ra n sf o r m i n g M e d i c i n e | Pa g e 8
Credible channels, actionable data dashboards, personalized communication, and patient-centric tools all contribute towards the industry’s attempts to bridge this gap for millennial doctors and their patients—to reach them at the right place, at the right time.
Ehr global Market 2016
$23.6b 2023
$33.3b Source: Visual Capitalist
B l o c k c ha i n i n H e a l t h c a r e
Introduction Globalization, increased adoption of information systems and related technology, and a sector populated with multiple actors in various jurisdictions, have given rise to a complex and self-proliferating health supply chain. Numerous efforts to protect supply chains in the broader context of all commodities and goods have been undertaken, including the United States (US) National Strategy for Global Supply Chain Security, which is a White House initiative to: “promote efficient and secure services” and “foster resilience”. While this federal strategy on supply chain security is important for any industry, a compromised supply chain in healthcare is of particular importance as it can result in a number of failures in healthcare delivery that directly impact patient safety and health outcomes. These include the threat of failing to secure and distribute lifesaving commodities, adverse events associated with supply chain breaches,and increased morbidity and mortality in the end-user or patient.
Su p p l y C ha i n M a n a g e m e n t | Pa g e 9
The pharmaceutical supply chain is one of the verticals most prominently considered when developing technology-driven solutions and use cases. For example, the global market for fake,substandard, counterfeit, and grey market medicines accounts for up to $200 billion per year. Studies have uncovered a host of pharmaceutical products, medical devices, and biologics, that have been subject to counterfeiting in World Bank categorized low,middle-income, and high-income countries indicating that the entire drug supply chain is susceptible to this transnational form of pharmaceutical crime. Coupled with international growth of the pharmaceutical market and a rise in global drug sales, the emergence of various forms of technology and digital health platforms has given rise not only to supply chain solutions but also vulnerabilities. Efforts to secure and modernize the supply chain have thus far focused on technologies such as radio frequency identification (RFID) chips with ownership transfer, mobile applications to track drug pedigree (e.g., m-pedigree), and other product verification solutions.
B l o c k c ha i n i n H e a l t h c a r e In addition to pharmaceutical falsification, improving security and mitigating vulnerabilities in the vertical space of medical commodities and devices is a priority area. The medical device industry is particularly important, given the rise in connected devices and mobile health (mHealth) applications. For example, patients with implantable cardiac devices have been rendered vulnerable due to gaping security holes, illustrating challenges associated with the growth of the Internet of Healthy Things (IoHT) and how its development and adoption has far outpaced security requirements. In response to challenges as with the cybersecurity vulnerability identified in the pace makers,government agencies and regulators are taking steps to increase awareness of the risks to the general public and healthcare ecosystem in the IoHT. Relatedly, rising healthcare costs tied to medical supplies are forcing healthcare systems to reexamine basic operating assumptions.While these processes would allow systems to better capitalize on a health system environment with large volumes of supply chain data, it still would not fully leverage it for supply chain optimization. Hence, effective management of the health supply chain is critical to ensuring optimal patient safety and population health level outcomes—a task that paradoxically relies on but fails to fully utilize cuttingedge technology and innovation. Failures in the health supply chain evidenced by the transnational trade in fake medicines, medicine shortages and stock outs, and security vulnerabilities in connected medical devices, illustrate the high stakes nature of this sector relative to some industries. As such, solutions must address and balance optimizing supply chain management and ensuring supply chain efficiency and risk reduction. In all healthcare verticals improving resilience, integrity, data provenance, and functionality of the health supply chain are essential.
Su p p l y C h a i n M a n a g e m e n t | P a g e 1 0
What is the common denominator to address these challenges? All of these and more critical challenges in healthcare could be addressed with superior supply chain management practices that are digitally enabled by blockchain technology. For the purposes of this perspective piece, we define a supply chain as the endto-end process from sourced raw material to final product sold to a customer. Areas within healthcare primed for improvements in supply chain management that we focus on in this paper include:pharmaceuticals, medical devices and supplies, IoHT, and public health. This perspective aims to raise awareness of opportunities for blockchain uptake in these health supply chain areas with a particular focus on the pharmaceutical supply chain, and also ask critical questions of what blockchain elements are crucial for future adoption and implementation. “PHARMA-CHAIN”: BLOCKCHAIN FOR THE PHARMACEUTICAL SUPPLY CHAIN? A serious and well recognized threat to the pharmaceutical supply chain is the infiltration of the combined category of substandard and falsified (SF) medicines; these are also referred to as counterfeit medicines but often taking on a different legal meaning. Collectively, these different forms of compromised and fake medicines can manifest as a result of importing substandard drugs without local approval, poor manufacturing practices or improper storage,theft and diversion of drugs, and the infiltration of poor quality or fake products into grey markets (i.e., business conducted outside of legitimate channels). The World Health Organization (WHO) estimates this combined market at $75 billion per year, but estimates range up to $200 billion. The pharmaceutical supply chain and healthcare system are particularly susceptible to disruption in countries like Vietnam, where the vast majority (i.e., 90%) of drug expenditures are contingent upon imported sources.
B l o c k c ha i n i n H e a l t h c a r e However, supply chain vulnerabilities are not limited to low-income markets or those heavily reliant upon drug importation. As an example, in 2012 the US Food and Drug Administration (FDA) notified nearly 1,000 healthcare facilities and practitioners in 48 states and US territories that they might have purchased and administered fake versions of the blockbuster anticancer drug Avastin® (bevacizumab). The legislative response to these threats in the US is the Drug Supply Chain Security Act (DSCSA). In a 10-year time frame, the DSCSA requires“medication tracking and tracing; serialization,verification, and detection of suspicious products; and strict guidelines for wholesaler licensing and reporting. Outside of the US,related efforts are underway with the Falsified Medicines Directive in the European Union(EU) and the Council of Europe’s MEDI CRIME Convention, along with local anticounterfeiting laws in various countries. When exploring the role of blockchain in securing and optimizing supply chain management for the manufacture, distribution, anddispensing of pharmaceutical products, the initial questions that should be posed are: would blockchain technology represent improvement over existing supply chain and anti counterfeiting systems and databases? Does it offer functionality or processes unavailable with centralized databases and legacy systems? How can a blockchain interact with existing supply chain data (e.g., RFID, Global Standards One(GS-1), Electronic Product Code Information Services (EPCIS), etc.) and anticounterfeiting technology? And finally, does it offer a compliance and regulatory solution that can mitigate risk but also better ensure compliance and patient safety that can benefit both manufactures and consumers? Answers to these questions should be the foundation of initial evaluations of blockchain design elements and feasibility studies to develop robust use cases,while also localizing within the context of the different challenges faced by supply chains in varying jurisdictions (e.g., EU parallel trade, markets with poor pharmaceutical governance).
Su p p l y C h a i n M a n a g e m e n t | P a g e 1 1
With the example of DSCSA, each regulatory component should map to blockchain capabilities for it to be a viable solution. In the case of the pharmaceutical supply chain, possible DSCSA-blockchain policy and technology alignment. BEYOND PHARMACEUTICAL SUPPLY CHAIN: OTHER POTENTIAL BLOCKCHAIN APPLICATIONS IN HEALTHCARE Moving beyond pharmaceuticals and the drug supply chain, blockchain applications are beginning to mature in other healthcare verticals,many of which are technologyfocused and heavily regulated. Arguably the most mature healthcare sectors moving forward with blockchain adoption are the clinical trial stakeholders, healthcare records and data management providers and entities, and as aforementioned, the pharmaceutical supply chain. However, areas for blockchain growth that align with the fundamental principles of improving data management and integrity of the health supply chain exist in areas of medical devices and supplies, IoHT, and public health applications, which are explored in brief below. Medical devices and medical supplies Recently, almost half a million patients with implantable cardiac pacemakers were identified as needing a vital firmware update due to a security flaw exposing their device to potential manipulation by hackers. This follows other instances, including the recall of the Symbiq Infusion System, after it was discovered that Hospira’s smart pumps could be accessed and controlled through a hospital network by unauthorized users to change patients’ dosages. As the employment of connected and digitally enabled medical devices becomes more prevalent, their opportune use as well as their vulnerabilities become more pronounced. In response to requirements for medical devices to bear a Unique Device Identifier (UDI) by the FDA and the EU, blockchain has the potential to reduce costs and improve patient safety, and combat medical device counterfeiting due to its efficiencies and accountability around trust. Use of blockchain could also enhance preventive maintenance of devices via deployment of automated smart contracts.
B l o c k c ha i n i n H e a l t h c a r e
Internet of Healthy Things The IoHT is a subset of the Internet of Things (IoT) focused on health and wellness. These“things” commonly include wearables, sensors,and standalone devices with utility including activity, sleep, cardiac function, and disease specific conditions (e.g., epilepsy). The vulnerabilities and opportunities with IoHT mimic those seen with medical devices, but IoHT often are associated with greater threats to data, security, and systems due to less rigorous requirements and testing relative to medical devices or devices that are less regulated (e.g.,non-FDA approved applications and devices)and more consumer focused. The Trusted IoT Alliance (https://www.trusted-iot.org/), formed by multiple industry IoT stakeholders, aims to help navigate these hurdles by facilitating standard setting and other efforts centering around leveraging blockchain for “connecting and securing the next generation of IoT products”.
Su p p l y C h a i n M a n a g e m e n t | P a g e 1 2
In the context of access to essential and quality medicines, blockchain technology solutions overlap with use cases in the pharmaceutical supply chain and combating SF medicines, but also extend to maintaining adequate supply at point of distribution (e.g.,mitigating stock outs), curbing health systems related corruption in medicines procurement,and catalyzing effective delivery of healthcare services and commodities. Blockchain technology in public health has also manifested as cryptocurrencies (e.g., digital currency like Bitcoin), which have been posited as alternative forms of currency that can be used to better effectuate foreign aid and charity and as a means to reduce fraud and corruption in global health, which can also intersect with disruptions and lack of resilience in supply chain integrity.
Authors 1. Kevin A. Clauson, PharmD, Associate Professor, Lipscomb University College of Pharmacy & Health Sciences,Nashville, Tennessee, USA. 2 Elizabeth A. Breeden, DPh, MS., Associate Professor and Director of Graduate
Public Health
Studiesin Health Care Informatics, Lipscomb University College of Pharmacy &
Supply chain challenges in public health include disaster and emergency mitigation and management, including protective supplies for healthcare workers during public health emergencies and access to essential medications, vaccines,and immunizations.
Health Sciences, Nashville, Tennessee,USA. 3. Cameron Davidson, PharmD, Pharmacy Curriculum Developer, PioneerRx, Nashville, Tennessee, USA. 4. Timothy K. Mackey, MAS, PhD, Associate Professor, UC San Diego – School of Medicine, San Diego, California,USA.
BOMRA
R e gu l a t i o n & P o l i c y | Pa g e 1 3
ABOUT US We are Botswana Medicines Regulatory Authority. We are a new body established by the Medicines and Related Substances Act (MRSA of 2013). Authority was set up by the Government of Botswana under the Ministry of Health & Wellness to regulate the supply chain of medicines and related substances cosmetics and medical devices in order to ensure their quality safety and efficacy.
B O M R A Va l u e C ha i n
R e gu l a t i o n & P o l i c y | Pa g e 1 4
T h e G r o w i n g I m p o r ta n c e o f E S G I n v es t i n g
Oshiro Sebogiso CFA Investment Professional Environmental, Social and Governance (ESG) factors and responsible investing principles have received much interest in recent years. The incorporation of ESG factors in an investment process can help give a much more comprehensive picture of the risk and return distribution of a company. It is therefore not a surprise that investors globally (including some Botswana pension trustees) are asking their money managers if, and how they incorporate ESG factors in their investment process. Part of this interest comes from investors’ belief that ESG or responsible investing should outperform a strategy that does not have ESG considerations. Furthermore, the interest stems from investors’ concern with corporate activities on the environment (think global warming); corporations’ violation of human rights (think labour standards); and the rampant misuse by corporate leaders of their agency responsibility. Moreover, there is an additional ‘feel good’ reward or appeal in investing in companies perceived to do and add positively to the world.
E S G I n s i g h ts | Pa g e 1 5 Several events come to mind when one thinks of the importance of ESG issues. In 2010, BP was responsible for what is still considered the worst oil disaster in history. At the time, investigations unearthed that the company had one of the worst safety and environmental records of any major oil company operating in the United States (Thomas, Jones, Jones & Ryan, 2010). The company had admitted to breaking environment and safety laws. Across the border, in 2012, Lonmin’s Marikana Mine labour clash had left 34 killed after the police opened fire on striking miners. These issues demonstrate the applicability of ESG factors in evaluating potentially risky and value detracting investments, given that companies report on this information. ESG investing does not suggest a blanket application to all investments. Each company (or industry) for instance would warrant specific ESG considerations applicable to that entity. An oil company, for example, would compel the analysis to focus heavily on the environmental factors whereas a technology company would have comparatively less environmental considerations. It is also crucial for investors to be aware that, ESG is not a substitute for rigorous fundamental valuation analysis. It is instead a tool that helps in that process.
T h e G r o w i n g I m p o r ta n c e o f E S G I n v es t i n g
E S G I n s i g h ts | Pa g e 1 6
For Botswana, it is currently a challenge to conduct a thorough analysis of ESG factors on listed (and unlisted) companies because of the lack of comprehensive disclosures on ESG practices by local companies and the absence of binding standards of disclosure of such information. A positive development is that the new BSE Equity Listings Requirements compels listed companies to follow the King III Code of Corporate Governance, which should aid in the analysis of governance issues. Moreover, the BSE released guidance on how listed companies can think through and implement ESG considerations in reporting. This is a step in the right direction. However, there is more that the investor can do. Activist shareholding and asking corporate managers to account for these issues is one way to get this information. With that, investment risk and return distributions can be better appreciated by investors. Â
Q & A w i t h D R G as e f e t e
A l t e r n a t i v e M e d i c i n e | Pa g e 1 7
Dr Carolyn Lebogang Gasefete 1) Please provide a brief biography of the Founder of Naturamedic; your background, qualifications and experience in alternative medicine. Naturomedic is a registered and licensed company. It was founded in 2015 by Dr Carolyn Lebogang Gasefete. Its main aim being to provide alternative or Natural and holistic health services to Botswana Community. Dr Gasefete is a board certified Natural Health Practitioner and Wellness Coach, she holds a Diploma in and Degree in Naturopathy and a certificate in Wellness Coaching. She is a member of the Complementary Medical Association and both certified by the CMA and the American Association of Drugless Practitioners. She is also a Silver member of the International Alliance of Holistic Therapists. She has 5 years experience in Alternative Medicine. She also holds various certificates from Various institutions including a certificate in Atrial Fibrillation from Stanford Medical School. 2) Give us an overview of Naturopathy,benefits and the difference to regular medicine. Naturopathic medicine is a system of primary healthcare that blends modern scientific knowledge with traditional and natural forms of medicine. It emphasizes the use of natural modalities—such as nutrition, lifestyle counseling and botanical medicine—to promote wellness and treat illness. It is a drugless, non invasive, rational and evidence-based system of medicine imparting treatments with natural elements based on the theories of vitality, toxemia and the self-healing capacity of the body, as well as the principles of healthy living. Naturopathic medicine is not defined by the substances used but rather by the principles that underlie and determine its practice, which include supporting the healing power of nature, finding the root cause of ill health, treating the whole person, prevention of ill health and promoting an interactive and supporting environment between the doctor and patient in a manner that mirrors that of a teacher and student. One of the most important tenets of naturopathy is that when the cause of disease is removed, the body will use its inherent abilities to heal itself, and the use of natural treatments can help influence these abilities. Naturopathic physicians are also trained in the conventional medical technique of clinical and laboratory diagnosis, and practitioners of naturopathy use these techniques as a regular part of their patient management. In summary, Naturopathic medicine (or naturopathy) is based on the belief that the body can heal itself. It aims to improve health, prevent disease, and treat illness through the use of organic foods and exercise; a healthy, balanced lifestyle; and the use of treatments from other areas of complementary medicine.
Q & A w i t h D R G as e f e t e
A l t e r n a t i v e M e d i c i n e | Pa g e 1 8
Benefits of Naturopathy Despite the significant strides and feats that are associated with western medicine, there are many cases where it does not adequately address the health problem. And in some cases it further aggravates the health problem to the point of fatality. The use of drug medicine though effective has serious side effects on patients or loss of life, for that reason Naturopathy set itself on a path that would offer an alternative approach to illnesses and other lifestyle diseases. Naturopathy emphasizes doing no harm to the body, preventing disease, encouraging the body’s inherent healing ability, treating the whole person and educating patients to be partners in their own health care. Naturopathy usually aids to reverse Chronic ailments with success in majority of cases. While helpful as it is, Naturopathy is not emergency medicine. COMMONLY TREATED CONDITIONS: Diabetes Insulin Resistance, Insomnia, Depression, Anxiety, Allergies- food and environmental based. Polycystic Ovary Syndrome (PCOS), headaches/migraines, Infertilit,y Pre-conception Care, Acne, Eczema, Cardiovascular disease, Arthritis Osteoporosis, Colds and Flue Cancer- Adjunctive care, Respiratory disorders, Metabolic Syndrome Obesity, ADHD and Autism. 3) Describe a typical appointment Initial appointments can vary from 20 minutes to 1½ hours depending on the naturopath. The most common length would be around 1 hour. This is where the naturopaths get to know you, your body and your health. The first 40 minutes usually involves a discussion about your body, any supplements or medication you’re currently taking, and your life style. Then the following 20 minutes involves designing a treatment protocol. A good naturopath will design a treatment plan that will achieve results but at the same time feels comfortable for the patient within their lifestyle. A naturopathic doctor has the time to explain your medication to you, help you make an informed decision about vaccinations and other medical interventions, provide nutritional and psychological counseling and provide guidance on treating a long list of conditions including: a weird skin rash, a cough or cold, a urinary tract infection, or any other complaint you might go to your family doctor or a walk-in clinic for. The nice thing about having a naturopathic doctor as your family doctor is that they will not only provide natural treatment for your health concerns, they will also both look into what is causing these concerns in the first place (is stress affecting your immune system, for example?) and treat them–preventing you from coming back with the same issue again.
Q & A w i t h D R G as e f e t e
A l t e r n a t i v e M e d i c i n e | Pa g e 1 9
 4) What is the local Market Value For Naturopathy? Naturopathy is a fairly new Medical disciplen in Botswana and still has a lot of teething problems. Batswana are still on the education part as far as Naturopathy is concerned. It does not have much promotion or advocacy from the Ministry of Health and majority of those who sit in the Health Professions Council to represent Naturopaths are from other Medical Disciplines rather than Naturopathy, therefore limiting growth and advocacy in general. Regardless of this, there is an ever increasing and rapid demand for alternative health care services in Botswana. According to association surveys, patients seek a naturopathic doctor after the solemn realisation that conventional medicine has failed to achieve its intended objective and effectively failed to meet the medical needs thereof.  Of the 6,000 random residents of Botswana asked why and when they seek Naturopathic Care, 65% of this number confirmed they would visit a Naturopathic Center when the Allopathic Health System has failed them while 35% verified they visit Naturopathic Medicine to maintain healthy lifestyles. These frequently detox and follow healthy diet regimes. The 65% however confirmed that the Allopathic health system always fails them hence a fall back to Naturopathy. Naturomedic is capitalising on this 35% and making sure to impress those who fall out from the 65% that Naturopathy is the way to go. On a study of 1,000 patients, 83% came to Naturomedic as a result of a satisfied patient referral, or word of mouth while 27% got word on Social Media and other advertisement forums. Over the last five years there has been a public epiphany in choosing natural methods for preventative health care as individuals look to take greater control of their health care needs. This trend has resulted in an increased demand for naturopathic services in Botswana.
Q & A w i t h D R G as e f e t e
A l t e r n a t i v e M e d i c i n e | Pa g e 2 0
 5) Career Advise for the youth who would want to consider naturopathy as a career A career in complementary medicine is more than just a 9-5 job. As a Naturopath you can expect to deal with a varied clientele, from pregnant women to their children, those with chronic health complaints and those who need assistance with acute conditions, people suffering from the constant high stress associated with many careers or for whom all alleopathic options have failed. The ultimate goal of the Naturopath is to gradually and gently improve a patients health, enabling and motivating them to make lifestyle changes that they can maintain long term. Treatment is aimed at the illness causing symptoms, not at masking the individual symptoms themselves. The body is treated as a whole, the physical, emotional and mental aspects are all catered for. Naturopaths are often a key member of a complementary medicine clinic, some may find employment as a consultant in a Doctors Office and some may branch out into their own business as individual practitioners. Naturopathy deals with the body as a whole. As such, naturopaths must have studied the human biological sciences from anatomy and physiology to cell and molecular biology as well as chemistry. They must also have up to date knowledge of pathophysiology and symptomatology, medicinal herbs, and a comprehensive understanding of nutrition, nutrients and digestive anatomy and physiology. Not a quick or easy program of study, but an interesting, challenging and rewarding one! Naturopathic medical education provides the foundation for many rewarding career choices. Your ND degree from an accredited institution affords a strong background in the medical sciences, clinical diagnosis and treatment, and the forefront of evidence-based natural therapies. While many graduates choose to focus their energy developing one pathway, a growing number combine one or more of these areas for professional flexibility and for the ability to create the work/lifestyle balance that is best for them. Most Naturopathic careers start with an Advanced Diploma to a degree for NDs . A degree is a 4-5 years programme of study depending on the institution used. it is important to study in an accredited institution.
Future Trends
Ou t l o o k | Pa g e 2 1
ESTIMATED HEALTH FINANCING GAP,
US$66B IN AFRICA
Source: 2019 Healthcare and Economic Growth in Africa Report
According to the 2019 Healthcare and Economic Growth in Africa report, Africa imports about 70% of the pharmaceuticals from outside the continent totaling $14.5 billion, and imports substantial health services. The regional statistics from the report mirror Botswana healthcare system which also relies heavily on imports, from pharmaceuticals, medical equipment to services for survival. In the aforementioned articles, we have explored various ways in which the healthcare sector can undergo a facelift to incorporate the 4th industrial revolution technology to leapfrog service delivery, patient care and access to information between patient and doctor in real time in order to improve patient experience and treatment.
Institutional investors have seen their investments grow in the past 12 months and are hungry for more bankable deals locally and regionally. The healthcare and economic growth in Africa report states that the private sector needs to leverage the African Continental Free Trade Area to invest in many under-invested sectors at continental level. The report states that there is an estimated health financing gap of $66 billion per annum for the continent based on the threshold of 5 per cent of GDP for government expenditure. Against the required $114 billion in current dollars, governments in Africa spend approximately $46 billion. This is a conservative estimate that is likely to increase over the years. More than half of this amount is required by Egypt (19 per cent or $12 billion) and Nigeria (32 per cent or $21 billion) (2019 Healthcare & Economic Growth in Africa Report).
100% of local healthcare businesses are privately owned and tend to grow organically through mergers and acquisition or from other private investors. Botswana is yet to have a publicly listed healthcare company on the Botswana Stock Exchange Limited. In the quest for economic diversification some historical under-invested sectors like healthcare are receiving the attention that they deserve. In the last two consecutive years we have seen the Ministry of Health and Wellness receive budget allocation of more than 16%, which is above the African region allocation of 5% of GDP of government expenditure..
Botswana Government has ambitious goals to be the destination of choice in health tourism regionally, which is reflected by the establishment of the teaching hospital, the recent launch of a wholly citizen owned hospital Sidilega and various changes in healthcare policies and reforms. This underdeveloped sector will undergo major developments over the next 5 to 10 years as more investment from institutional investors and private investors flows in to bridge the financing gap. The state of the art facilities and highly trained specialists will divert the traffic of clients traveling outside the continent for treatment to consider Botswana as the healthcare destination of choice.
Lindiwe Mafavuneh Founder & CEO LCM Capital Research & Analytics Unit
LCM CAPITALÂ RESEARCH & ANALYTICS