Medical Credit Fund Progress Report 2011-2012
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Preface After having concluded a pilot program in 2010, the Medical Credit Fund program was successfully rolled out in Tanzania, Kenya and Ghana. The Fund managed to enroll just over 200 healthcare facilities in the program, 157 clinics attended business training and 143 enrolled in quality training and the MCF had disbursed 157 loans. Demand for loans and technical assistance among healthcare facilities has proved to be significant since the beginning of the MCF program. Recent research has once more confirmed that access to credit and the need for business support are the most persistent impediments to an increase in operations and quality of services. At the MCF we are able to offer both to primary healthcare facilities in a package deal which may explain the popularity of the program. The MCF operations are mainly carried out by local partners. The MCF is privileged to work with high caliber technical assistance partners that work closely with participating healthcare facilities. All have built specialized capacity and installed dedicated teams for the program, and they all have indicated they want to stay on board for years to come which will allow for continuity and stability. Likewise, the MCF is very pleased to have signed agreements with well reputed local banks that are responsible for the actual lending activities and customer management. Over the course of 2011 and 2012 the MCF has progressed in further capital mobilization to sustain and expand its operations. Facilitated by winning the G20 SME Finance Challenge Award and the ensuing publicity, the MCF has attracted funding of international public and private investors. This builds confidence in the future of the Fund and the ability to fulfill its mission. Monique Dolfing-Vogelenzang Managing Director October 2012
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Our Mission The vision of MCF is to make good quality basic health care accessible to everyone in Africa. The mission of the Medical Credit Fund is to contribute to building a high quality healthcare system by enabling private healthcare providers to fully explore and develop their potential as key players in the healthcare sector. The main objectives of the MCF are to strengthen the business cases of primary healthcare providers and to improve the quality of their clinical and medical services by facilitating access to investment capital and by providing business advice and top quality technical assistance.
The MCFâ€™s vision is to make basic health care of good quality accessible to everyone in Africa.
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Health care in Africa In most African countries the public sector is unable to meet the growing demand for health care. Therefore, 50 percent of the people turn to the private sector instead. The potential of the private healthcare sector to complement the public system is now increasingly recognized by African governments as well as the major donor organizations and development banks. In fact, it is expected that the private sector will grow between USD 11 and 20 billion in the next decade, driven by sustained economic growth of many African countries leading to an increased demand for healthcare services. So far, however, this has not translated into the required investment allocations to sustain this growth of the sector. Partly, the lack of investments can be attributed to the general investment climate in sub-Saharan Africa where institutions are weak and transaction costs are high. But in addition, the private health sector is highly fragmented, and suffers from a lack of information and standards. Investors have limited knowledge of the specific features of the private healthcare sector. There are no financial and medical investment benchmarks to go by. Revenue streams are erratic due to the high dependency on out-of-pocket payments in health, which may affect the business case of private care providers. As a result, many investors continue to shy away from investing in the private healthcare sector because of the unknown and high risks. And if they invest in private health at all, they feel obliged to levy high surcharges and mark-ups to cover all risk, which result in unaffordable costs of capital for most providers. Thus, the health system is left in a vicious circle, with low trust, low demand and low willingness to pre-pay, few investments and low quality supply.
Underfunded private sector
The vast majority of private healthcare providers in Africa are small and medium enterprises (SMEs) and they also represent the segment of the private healthcare market that is most underfunded. This SME segment 6 Medical Credit Fund
covers a wide variety of organizations: smaller hospitals, diagnostic centers, health centers, dispensaries, maternity homes, health shops and nurse-driven clinics. It is there where most Africans seek care if they do not visit a public facility, which is in roughly 50% of all cases. Two-thirds of these SMEs would need additional capital below the USD 250,000 mark. Yet, it is primarily these health SMEs that are deprived of investments. Apart from the general reasons affecting the private healthcare sector, they face some additional challenges. Most have no credit history and a good many have no adequate bookkeeping and accounting system and no financial performance records to show. In addition, many do not have sufficient assets to securitize formal bank loans. Besides, most SME owners are medical professionals and not experienced entrepreneurs. They give priority to serving their patients rather than running the business. All in all then, there are additional reasons why health SMEs often find it difficult to deal with banks: they are barely bankable. This does not represent ill-will on the part of the banks. In fact, many favor becoming involved in the healthcare sector as an expression of socially responsible banking and contributing to a public good. But strict internal and regulatory lending guidelines make actual deal-making opportunities slim.
feel comfortable enough to see the potential of an emerging asset class.
To break the vicious circle, setting standards and building trust (i.e. reducing uncertainty and risk) are critical and therefore central to the MCF approach. At the same time local circumstances dictate a bottom-up approach. Health SMEs are the chosen target market for the MCF. Investment needs are high and the prospect of social and medical impact is highest in this segment. Given the challenges, this is not a segment now ready for investment. It is a segment where prospective borrowers need to be prepared to borrow from the local capital market and where investors need to gain experience to
That is the rationale for the technical assistance program. The MCF business advisors work with health SMEs to reconstruct annual statements, propose efficiencies in management and operations, scan the market for growth opportunities and finally produce a convincing business plan. And its quality advisors work with the same SMEs to install or upgrade clinical procedures and protocols, improve performance areas and prepare for quality assurance through certification and accreditation according to the SafeCare methodology.
Yearly Independent Assessment
6. Excellent quality systems in place: healthcare provider has a proven track record of continuous quality improvement, is in substantial compliance with the SafeCare standards, and meets the decision rules for accreditation by independent organization COHSASA. 5. Demonstrates long-term commitment to continuous quality improvement, ready for accreditation program and self sufficiency of continuous quality improvement. Very limited technical assistance required. 4. Strong quality systems in place, but high-risk areas still in need of attention. Limited technical assistance required. 3. Medium quality strength, acceptable but vulnerable to changing environment. Focus on self evaluation of quality improvement processes using quality indicators, guidelines and standard operating procedures. 2. Modest quality strength, requiring medium technical assistance. Health care quality is still likely to fluctuate. Focus on the securing of quality systems, and processes especially in high risk areas. 1. Very modest quality, with continued need for periodic technical support. Focus on implementation of processes and quality systems and the availability of financial means to ensure availability of proper infrastructure and assets. 0. Poor quality however the organization has shown leader足ship commitment and a strong desire to provide safe health care and recognizes that significant improvements are needed to reach levels of consistent, efficient, safe quality care for each patient. It has fluctuating quality healthcare provision due to the unavailability of services at times.
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Founded in 2011 by PharmAccess, the Joint Commission International (JCI) of the U.S.A and the Council for Health Service Accreditation of Southern Africa (COHSASA), SafeCare acts as the custodian of internationally recognized, unique sets of standards that are realistic for resourcerestricted settings while not compromising on quality levels. SafeCare standards focus on â€˜bottom of the pyramidâ€™ public and private healthcare facilities such as dispensaries and health centers, that make up the main healthcare delivery channel for low-income settings and that struggle with patient safety and quality demands. The methodology dissects the improvement process of healthcare providers in survey-able, measurable steps. Thus, an improvement
path is created that offers positive incentives for healthcare providers to move upwards in quality, ultimately to the level that qualifies them for full accreditation. Whereas the latter objective might remain out of reach for most providers for some time to come, a guided way to work towards that objective will boost client, investor and regulator confidence in the motivation and capacity of healthcare providers to steadily enhance their performance. All quality improvement efforts are supported by innovative data collection and reporting tools, allowing for real-time facility assessment and online monitoring. In addition, the data collected on clinical performance allows for prioritization of financial resource allocation which enables a more efficient use of available resources.
Scope of the MCF program
Tertiary/teaching hospital All specialized services, incl. complex curative interventions. Full range of (para)medics and specialists. HIMS is used for data capturing/analysis. Laboratory, radiology and pharmacy services available. Referral hospital Providing a broad spectrum of medical
2 procedures except specialized treatment. Includes complicated abdominal services.
Primary health center Medical doctor, nurse and lab technician
4 offering minor surgery and chronic disease management.
hospital Providing 24 hrs service, maternal health, 3 District HIV and TB treatment, minor and some major surgery.
Basic health center Staffed by clinical officer offering general
5 health and maternal health care.
6 Health shop/nurse clinic Giving advice on basic healthcare issues.
The MCF mainly operates in segments 3-6 of the private healthcare market. These are the segments where health SMEs are active. 8 Medical Credit Fund
Interview with Fordson
“The Medical Credit Fund program provided an entry route into these clinics for Banc ABC.” “There is a big challenge in financing the small and medium sized enterprises (SME) in the health sector in Tanzania. The biggest challenge is lack of information as the majority of SMEs does not have a proper bookkeeping system nor do they keep accurate records of transactions Nevertheless, the SME health sector is potentially an interesting sector to invest in: it is a new sector to lenders and has massive opportunities that come with its rapid growth. “The MCF program provided an entry route into these clinics for Banc ABC. The Medical Credit Fund program made the clinics more bankable through the technical assistance program which includes financial management training. The program enables banks to develop a deeper understanding of the SME health sector financing and build valuable skills that will allow them to structure appropriate loan products for the private health sector.
“The partnership is guided by a formal agreement between BancABC and MCF, wherein all the roles and responsibilities are defined. For example for entry loans; the MCF funds the loan 100% and assumes all the risk. The bank’s responsibility is to assess the creditworthiness of the clinic, approve loans for creditworthy clinics, monitor the performance and report to MCF on a monthly basis on how the loan portfolio is performing. Moreover, the bank provides financial advice. Visits are generally done once a quarter as part of the monitoring process.“ Musingarabwi, Head of Credit at BancABC, banking partner of the Medical Credit Fund in Tanzania.
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Achievements All these activities make health SMEs bankable. The vast majority of participating health SMEs indeed make the threshold: they do access a modest first loan and a larger second one. First generation lenders in the MCF program have seen their business increase and their quality performance improve. They attract more patients, provide better services and are in better financial shape than before.
In the meantime, the MCFâ€™s partner banks review their risk perception and gain trust in the private healthcare sector. They are then keen to take over the best performing health SMEs as their own clients. In fact, the MCF portfolios are among the best performing portfolios on their books. This sustains confidence in the MCFâ€™s investment strategy.
By mid 2012 the Medical Credit Fund was fully operational in Tanzania, Ghana, Kenya and Nigeria. In all countries similar programs have been developed. These are based on an intricate pattern of cooperation between clinic, technical assistance provider, bank and the MCF. Standardized flowcharts, procedures and protocols have been introduced to guide and streamline operations.
Association of Private Health Facilities in Tanzania (APHFTA)
Kisumu Medical and Educational Trust (KMET), PSI/KENYA
Merchant Bank Ghana (MBG)
PharmAccess Ghana, Society for Private Medical and Dental Practitioners (SPMDP), Ghana Registered Midwives Association (GRMA)
First City Monument Bank (FCMB)
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These activities follow the major program design of the MCF which consists of two parts: the technical assistance program (TA) which assists clinics in upgrading their clinical and business performance and the finance program that creates access to capital through local banks. The TA program contains comprehensive financial and clinical due diligence, the results of which are captured in quality upgrades and business plans. The latter forms the basis of loan applications submitted to the MCF and to the bank for approval. The MCF endorsement allows for underwriting of the bank´s loans. In the meantime a robust back-office capacity was developed to handle the flow of information and performance data so that the MCF can adequately report. This consists of all loans provided by local banks to participating clinics with MCF support. By September 2012 the MCF had disbursed 156 loans: 38 in Ghana, 42 in Tanzania and 76 in Kenya. Overall disbursements for these loans amounted to USD 1,092,827 of which USD 578,496 was still outstanding. The overall repayment performance of loans is 99.1 %. This means that only 0.9 % of the outstanding loans are overdue on their payments by 90 days or more. By September 2012, 157 clinics had attended business training and 143 had enrolled in quality training. With the support of the SafeCare program, the TA providers were able to conclude 160 clinical entry assessments and four full scale certification exercises.
Medical Equipment ICT Fixed Assests Medical Stock / Inventory Accounts & other expenses
The pie chart above provides an overview of what the disbursed loans so far have been used for. The loans disbursed are primarily spent on renovations and medical equipment. Popular items in the medical equipment category are hematology analyzers, ultrasound scanners, delivery beds, and microscopes. ‘Fixed assets’ concerns investments in, for example, generators, air conditioners, refrigerators and incinerators. ‘Accounts and other expenses’ refers to having annual accounts produced as a prepartion for a follow up loan, developing standard operating procedures, guidelines, and protocols.
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Nyamira Maternity & Nursing Home Kenya
“New patients report themselves because now it is clean and safe.” Dr. Peter Nyangochonga is the owner of Nyamira Nursing Home, a small hospital with 24 employees and 12,000 registered patients half of whom belong to low income groups. The doctor requested for a loan through the MCF to deal with primary quality issues. With the approved entry loan of USD 3,000 the waiting room has been improved, the clinic has been painted, the waste problem has been solved, quality protocols have been introduced and a sterilization machine for the operating room has been bought. Dr. Peter: “With this small loan and the excellent advice of the MCF we were able to achieve something we had planned long ago. We have a step-by-step strategic plan for every department. With the next loan we would like to purchase an ultrasound and set up a maternity ward. We have noticed that the patients really appreciate these improvements. New patients now come forward as the clinic is clean and safe. Therefore the loans repay themselves”.
MCF Category 3: District Hospital Entry loan Loan Amount 300,000 KES (EUR 2,800) Total staff members 24 Medical staff 6 Para-medical staff 5 Support staff 13 Patients per month 1,248
Bonda La Mpunga Dispensary Tanzania
“The number of patients is increasing daily due to the improved service we offer.” Dr. Hassan Ahmad is the owner of Bonde La Mpunga Dispensary, a small dispensary in Tanzania with a staff of twelve. The MCF provided a 19 million shilling (EUR 9386) loan to improve the facility. Dr. Ahmad: “We used the loan to renovate the clinic and to improve the quality of our service. Among other things we contracted a gynaecologist who comes every Saturday. Dr. H. Ahmad is visited frequently by the technical assistance partner APHFTA for training and technical assistance. APHFTA trained the doctor and staff members on among others diabetes, HIV/AIDS and on setting up a financial management system. APHFTA supported their inclusion in the MCF program. “Before we could apply for the loan we had to get our bookkeeping in order. Once that was done we made a plan with a contractor and sent it to APHFTA and later to the bank. We have now developed a good relationship with the bank that provided the loan and have repaid more than half of our loan. Bank staff visit the clinic regularly to monitor progress and educate the accountant.” “The number of patients is increasing daily due to the improved service we offer. The renovated building has provided a much fresher atmosphere. We now serve up to 60 patients a day. Before the renovations this was around 20. Many people from the community have expressed their appreciation for the new situation to me.”
MCF Category 5: Basic Health Center Medium loan Loan Amount 19,000 TZS (EUR 9,386) Staff members 10 Medical staff 6 Para-medical staff 3 Support staff 1 Patients per month 750
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Clinics and Results 210 Total number of health facilities in the MCF program 54
Kenya 17 3
Ghana 16 7
Category 0: No data Category 3: District Hospital Category 4: Primary Health Center
Category 5: Basic Health Center Category 6: Health Shop Data until 31 Augustus 2012
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5 Number of banks
Total number of disbursed loans
Total disbursed loan amount
Loan repayment performance
Current oustanding amount
Patients & Care
15,765 HIV tests performed
Top 3 diseases treated at these clinics
1. Malaria 2. Hypertension 3. Pregnancy
Number of patient visits
Family planning visits
210 Total number of clinics
= 2581 Total number of health care staff at clinics
29 Number of local technical assistance advisors
Quality investment Top 4 quality improvement areas
Top 3 priority areas
1. Medical Equipment 2. Renovations 3. Fixed Assets 4. Medical Stock
1. Infection control 2. Basis infrastructure and equipment 3. Staffing & skills
151 Total number of SafeCare assessments
Quality improvement plan
Business plan finished
SafeCare Certificates V 0 IV 0 III 1 II 3 I 1 Entry level 4
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Our ambition 2011 was the year of rolling out the Medical Credit Fund program, the yearÂ 2012 is used to scale up activities in Tanzania, Kenya and Ghana. The MCF has also started preparation for initial activities in the fourth country, Nigeria, and the MCF is looking to expand its program to at least one other sub-Saharan country in 2013 and 2014. In the overview below the MCF goals on the number of training sessions, the SafeCare level of improvement, loan provisions and disbursed loans are listed for the coming years. The objectives set for 2013 are promising.
The Medical Credit Fund trained over 200 medical professionals over the past three years. The MCF organized seminars and sponsored training in business or quality improvement to improve the skills of health staff. A realistic target for the end of 2012 is to have 300 medical professionals trained, 500 in 2013 and 700 by the end of 2014. By September 2012 the 9 clinics achieved a SafeCare level of improvement. Under the SafeCare quality program progress made by the facilities is measured and recognized by five pre-defined steps or levels of improvement. Compliance with these steps will be awarded with an official Certificate of Improvement. The MCF aims to award new Certificates to at least 11 more clinics before the end of 2012, 30 clinics by the end of 2013 and in December 2014 the target is 110. All of the healthcare providers in the MCF program will be assessed and graded according to SafeCare.
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The Medical Credit Fund works in partnership with African banks to handle the loan provisions to health facilities. Local healthcare organizations select, recruit, train, support and guide these health facilities into becoming eligible for a loan from the banks.
Interview with Meggy
“The program is a marketing tool for KMET as the demand for quality has long been ignored in the private sector.” “As Senior Quality Assurance Officer I provide technical support to health facilities taking part in the quality improvement process of the Medical Credit Fund Program. This support includes assisting in the clinic selection, entry-assessment, develop upgrading plans, monitoring progress of implementation and intermediate quality assessments. An example of what this means in practice is a visit to the Dunga Nursing Home, which is a new clinic to the program. I ensured the clinic met the quality criteria prior to enrollment and offer comprehensive primary health care. I would make sure they were legally registered, served both poor and above average clients, willing to participate in the program and are motivated towards quality improvement. “Once a facility has enrolled into the program and signed a participation agreement, I conduct a situational analysis to understand the case load, staffing issues and growth opportunities.
My counterparts in the business team develop an expert opinion and facilitate the entry loan process. Once the entry loan is disbursed, I conduct an entry assessment to determine the level of quality being offered in the facility vis-a-vis the SafeCare standards. The results are analyzed at the Amsterdam office and the feedback is shared with the facility through me. Then the facility awaits the upcoming training. “My long term expectations for this program are positive. The program is a marketing tool for KMET as the demand for quality has long been ignored in the private sector. It also strengthens other programs by providing an implementation strategy for the other projects through the SafeCare standards checklist. Since quality sells itself, better services and introduction of new services, will ensure that referrals can be reduced, clients will be more satisfied, staff will be retained longer, which will thus lead to sustainable quality.”
Meggy Agola is Senior Quality Assurance Officer of Kisumu Medical & Education Trust in Kenya. KMET, is a technical assistance partner of the Medical Credit Fund in Kenya.
Financial overview The MCF has announced its first closing of investments in October 2012. The participating investors are the Overseas Private Investment Corporation, Calvert Foundation, Bill & Melinda Gates Foundation, Soros Economic Development Fund, Deutsche Bank Americas Foundation and Dutch private investors. The MCF is a hybrid fund: financed by blending grants, equity and debt financing from both public and private parties, which are used for technical assistance (grants), first loss (equity-grants) and debt financing (loans). The first loss equity facility within the Fund’s structure is destined to provide a cushion for the debt investors and can absorb loan losses and currency exchange
Loans in USD 435,729
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2011 has been the first full year of the MCF’s lending activities and in some countries the MCF has moved beyond the start-up phase. Until early September 2012, the MCF has disbursed a total amount of USD 1,092,827 in loans, divided in USD 504,903 in entry loans and USD 587,924 in medium loans. Over the last quarter of 2012 and in 2013, the number of medium loans is expected to substantially increase further as many clinics have completed their entry loan stage and will apply for the larger, medium loans under the MCF program.
Entry Loan - Disbursed 8,529
For funding of the Technical Assistance costs, the Fund has received grants from both public institutions and private foundations. Grants have been provided by several Dutch private donors, De Grote Onderneming, Aids Fonds, FMO on behalf of the Dutch Ministry of Foreign Affairs, USAID and IFC on behalf of the Canadian Government.
The audited financial result over 2011 on the MCF’s loan portfolio has been positive, mainly caused by a large positive exchange rate effect. Over the first half year of 2012, the MCF has not benefitted from a positive FX result and the loan portfolio shows a
rate risks. This facility thus leverages the debt financing from private investors and Development Finance Institutions (DFIs).
Medium Loan - Disbursed Entry Loan - Outstanding Medium Loan - Outstanding
Approved Funds for 2012-2018 in USD 20,000,000 5,525,000
marginal negative result. This low margin is largely due to the relative high portion of entry loans in the portfolio in the start-up phase of the MCF program. Entry loans have higher management fees and a higher risk profile as these loans are issued to first-time, financially less experienced clients. As the clinicâ€™s business administration and health care quality improve as a result of the Technical Assistance, the MCF expects the risk to reduce for later stage loans.
Financial leverage graphic 80,000,000 70,000,000 70,000,000 57,500,000
10,000,000 370,250 345,250 0
4,000,000 10,000,000 3,000,000
Cumulative total loans in dollars provided to clinics (by local banks and MCF) Part of the loans in dollars which have been funded by MCF
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Board and Management The MCF Management Monique Dolfing-Vogelenzang, Managing Director, Board Member Bart Schaap, Director Finance, Board Member Herman Abels, Director Operations Tom Bouma, Senior Financial Analyst Hanneke Peeters, Senior Quality Manager, PharmAccess Anna Theuvenet, Process Manager Marceline Obuya, Program Manager East Africa Joost Zijlmans, Finance Control
Supervisory board Onno Schellekens, Chairman Managing Director Investment Fund for Health in Africa. Klaus Vink, Vice-President Solicitor and tax lawyer and senior partner at Vink & Partners. Tobias Rinke de Wit Director Business Development and Research allocated by PharmAccess to the Council for Health Service Accreditation of Southern Africa, Cape Town. Hans van Veggel Real estate developer and Founder and President of Multi Vastgoed/ Multi Corporation and co-founder of the Medical Credit Fund. Ton Coenen Executive Director Aids Fonds & SOAAIDS Nederland. Frank Eijken Owner and Manager of Eijken Management & Consultancy. Ben Christiaanse In 2006 he was appointed as CEO of National Microfinance Bank in Tanzania. He developed NMB into one of the largest financial institutes of Tanzania. He now provides consultancy, specially focused on financial institutes in developing countries.
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Group of organizations Medical Credit Fund was initiated by PharmAccess and is part of a group of organizations serving the same purpose. PharmAccess is a Dutch not-for-profit organization dedicated to improve health care in Africa through innovative approaches. We believe that supporting and involving the private sector in the delivery of health care is crucial in countries where governments are not capable to provide public health nationwide. Donor money can be effectively used to increase trust in the health system, lower the investment risk and transaction costs and mobilize private sector investments. PharmAccess contributes to the development of health systems by stimulating both the demand and supply side, measuring and improving quality and increasing the amount of money in the system, leveraged by donor contributions. The organization has set an example as a different way of development cooperation making use of public-private partnerships. This approach has attracted a lot of international attention, including a G20 prize for our innovative financing model presented by President Obama in 2010. PharmAccess and its related foundations mobilize public and private resources for the benefit of doctors and patients through insurance (Health Insurance Fund), loans to doctors (Medical Credit Fund), clinical standards (SafeCare), private investments (Investment Fund for Health in Africa) and operational research (Amsterdam Institute for Global Health and Development). Together, this group of organizations serves the purpose of making good health care accessible to everyone in Africa, leading to healthier populations and social and economic development. Our partners, donors, investors and clients include Dutch and African (local) governments, local health maintenance organizations and insurance companies such as Hygea, AAR and MicroEnsure, international (donor) organizations such as World Bank/IFC, United States Agency for International Development (USAID), International Labour Organisation (ILO), Clinton Foundation, DFID, Marie Stopes International and PSI, international public and private investors, multinationals such as Heineken, Shell, Zain, Air France KLM and health accreditation organizations such as Council for Health Services Accreditation for Southern Africa (COHSASA) and Joint Commission International (JCI).
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Trinity Building C Pietersbergweg 17 1105 BM Amsterdam Phone: +31 (0) 20 566 7158 Fax: +31 (0) 20 566 9440 firstname.lastname@example.org www.medicalcreditfund.org
The progress report highlights the achievements and results that the Medical Credit Fund managed to realize over the past two years.