AFRICAN DEVELOPMENT BANK GROUP

STRATEGY FOR QUALITY HEALTH INFRASTRUCTURE IN AFRICA

2022-2030

REVISED VERSION

February 2022

AHVP/AHHD
 Contents
Acronyms……………………………………………………………………………………………….i
Voices on healthcare in Africa…………………………………………………………………………ii
Acknowledgments.................................................................................................................................. iii
Executive summary…………………………………………………………………………...iv
1. INTRODUCTION .......................................................................................................................... 1
2. THE CASE FOR INVESTING IN HEALTH INFRASTRUCTURE IN AFRICA ....................... 2
3. AFDB’S COMPARATIVE ADVANTAGE ON HEALTH INFRASTRUCTURE ....................... 8
4. LESSONS LEARNED.................................................................................................................. 11
5. OBJECTIVES AND STRATEGIC APPROACH ........................................................................ 12
6. PRIORITIES UNDER THE STRATEGIC PILLARS ................................................................. 14
7. IMPLEMENTATION OF THE STRATEGY .............................................................................. 18
8. RISKS AND MITIGATION ......................................................................................................... 22
9. CONCLUSION………………………………………………………………………... 23

Figures
Figure 1: Africa’s diverse health needs ..................................................................................... 3
Figure 2: Focus areas for development partners in African health infrastructure ................... 10
Figure 3: Theory of Change ..................................................................................................... 13
Figure 4: Linkages to other Bank strategies ............................................................................ 21
Figure 5: Risk and Mitigation Measures .................................................................................. 22

Boxes
Box 1 : Use of incentives to stimulate diaspora investment in the Indian health sector............ 6

Annexes
Annex 1: SQHIA Results Framework
Annex 2: SQHIA Action Plan
Annex 3:Strategic Approach to Partnerships in Support of Africa’s Health Infrastructure
Annex 4: Bank’s Support for COVID-19 Response in South Sudan
Annex 5: Methodology for Assessing Health Infrastructure Deficits
Annex 6: Analysis of Financial Flows into Africa’s Health Infrastructure
Annex 7: Lessons on Telemedicine from the Bank’s Medical Centre
Annex 8: The Bank’s track record on health infrastructure, 1975-2021
Annex 9: External Stakeholder Consultations
Acronyms
AfDB African Development Bank
ADF African Development Fund
ADB Africa Development Bank
AHHD Human Capital, Youth and Skills Development Department
AIF Africa Investment Fund
ALSF Africa Legal Support Facility
AU African Union
CD Communicable disease
CDC Centers for Disease Control and Prevention
CSP Country Strategy Paper
DALY Disability-adjusted life year
DFI Development Finance Institution
ICT Information and Communication Technologies
ICU Intensive Care Unit
IFC International Finance Corporation
HHA Harmonization for Health in Africa
IsDB Islamic Development Bank
KPI Key Performance Indicator
LIC Low Income Country
M&E Monitoring and Evaluation
MRI Magnetic Resonance Imaging
NCD Non-Communicable Disease
ODA Official Development Assistance
P4H Providing for Health
PHC Primary Healthcare
PPP Public-Private Partnership
RMC Regional Member Country
SDG UN Sustainable Development Goal
SQHIA Strategy for Quality Health Infrastructure in Africa
TA Technical assistance
UHC Universal Health Coverage
UNECA United Nations Economic Commission for Africa
UNICEF United Nations International Children's Emergency Fund
USA United States of America
WASH Water, sanitation and hygiene
WHO World Health Organization

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Voices on healthcare in Africa

We must give hope to the poor and the vulnerable, by ensuring that every African, regardless of their
income level, gets access to quality health care, as well as health insurance and social protection.

Dr. Akinwumi A. Adesina, President, African Development Bank Group, 2021

You cannot end extreme poverty if you are neglecting the investments in health and education that
are so critical to economic growth… It is not one thing. It is the health workers, it is hospital beds, it
is making sure that you can provide oxygen, and then it is going to be production capacity for
vaccines, and this all has to happen very quickly.

Dr. Jim Yong Kim, Former President, World Bank, 2021

Dr. Jim Yong Kim, Former President World Bank, 2021

Ebola was a signal. We can also look at Covid-19 as an indication that something more severe will
come if we do not strengthen our health defences.

Dr. John Nkengasong, Director, Africa Centres for Disease Control and Prevention, 2021

I welcome the [Bank’s] Strategy, which is very comprehensive, and it is excellent to see that the
Bank plans to support and align with national health system strengthening strategies, which are
foundational for sustainable development.

Dr. Lia Tadesse, Minister of Health of Ethiopia, 2021

Covid-19 pandemic had exposed the fragility of health systems and infrastructure deficit in the
ECOWAS region. The Ministers of Health in the ECOWAS region appreciate and commend the
support and leadership role of their development partners such as the African Development Bank
Group in the development of quality health infrastructure across the continent.

Dr. Osagie Ehanire, Minister of Health of Nigeria, 2021

We congratulate the Bank on this strategy, it is well-written, well-designed, and really targets the
current health infrastructure situation on the continent.

Ms. Aisa Muya, Head of Programmes, African Medical and Research Foundation, 2021

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Acknowledgments
Preparation of the Strategy for Quality Health Infrastructure in Africa was led by the Human Capital,
Youth and Skills Development Department with inputs from a diverse group of experts in the Bank’s
departments and externally. The Strategy was prepared by a Core Team of Bank’s experts led by Martha
PHIRI, Director, Human Capital Youth and Skills Development, under the guidance of Beth
DUNFORD, Vice President, Agriculture, Human Capital and Social Development. A technical team
supported by external consultants completed a scoping and comparative advantage study, in which
SQHIA is grounded, and drafted the strategy. This technical team was led by Babatunde Omilola
(Manager, Public Health, Nutrition and Social Protection Division) and comprised Fabrice Sergent
(Task Manager), Peter Ogwang (co-Task Manager), Maïmouna Diop-Ly, Patience Kuruneri, Nana
Kgosidintsi, Elizabeth Owiti, and Arun Kumar. The Strategy also benefited from valuable comments
provided by Aissatou Ba-Okotié, Mukaila Ojelade, Hailu Mekonnen, Tapera Muzira, Hendrina Doroba,
Sering Jallow and Tom Owiyo.
Members of an Inter-Departmental Task Force from different AfDB departments reviewed the Scoping
Study and the initial draft of the Strategy to ensure relevance of the issues as well as the analysis and to
promote AfDB-wide ownership of the Strategy. Colleagues at the African Development Bank (AfDB)
who made substantial contributions include: Charlotte Ako Eyong; Menako Asare-Bekoe; Adele
Boadzo; Roza Bora; Oley Cole; Thierno Diarra; Ijeoma Emenanjo; Victoria Flatteau; Etambuyu
Gundersen; Toussaint Houeninvo; Alex Mbaraga; Merman Nare; Edward Nsobe; Grace Obeda; Eline
Okudzeto; Njeri Wabiri; and Alex Yeanay.
Inputs were also provided by Penny Jackson (Division Manager, Quality Assurance), Debazou Yantio
(Principal Evaluation Officer, BDEV), George Kararach (Lead economist, Southern Africa), Andoh
Mensah (Manager, Trade and Investment Climate), Mike Salawou (Division Manager, Infrastructure
and Partnerships), Rane O’Neil, Maimuna Nalubega, Jean-Jacques Nyirubutama, Rosemary Mokati-
Sunkutu, Florence Zodwa, Patrick Kanyimbo and Lydie Ehouman.
Substantive comments and guidance were received from the Senior Leadership Group chaired by the
Bank’s President. Vice Presidents, Directors-General and Sector Directors also provided insights.
Special thanks go to Vice President Solomon Quaynor, Vice President Rabah Arezki, Vice President
Khaled Sherif, Prof. Oyelaran-Oyeyinka, Special Advisor to the President, DG Leila Mokaddem, DG
Mohamed El-Azizi, DG Nnenna Nwabufo, Ag. DG Josephine Ngure, Senior Director Ebrima Faal,
Victoria Chisala, Karen Rot-Munstermann, Malinne Blomberg, Abdu Mukhtar, Amadou Oumarou,
Soumik Paul and Alex Mubiru.
The insightful feedback received from external reviewers and participants in the external consultations
undertaken to date are also gratefully acknowledged. These include, but are not limited to, Mohammed
Ali Pate (Global Director for Health, Population and Nutrition, World Bank), Biju Mohandas (Principal
Investment officer, IFC), Renee Awembeng (Global Head, Client Relations, Afreximbank), Mr.
Saurabh Sinha (United Nations Economic Commission for Africa), Dr. Amit Thakker (Africa Health
Business); and Dr. Padmashree (Harvard University). We thank all the experts from the private sector
who provided important suggestions to improve the quality and relevance of the strategy.
Last, but not least, insights were received through a knowledge event organised on the margin of the
Bank’s 2021 Annual meetings. We wish to thank Dr Jim Yong Kim (Vice-chairman and partner of
Global Infrastructure Partners and former President of the World Bank); Mr. Ken Ofori-Atta (Minister
of Finance and Economic Planning of Ghana); Mr Ali Kooli (Minister of Economy and Finance of
Tunisia); Mr. Ayman Benabderrahmane (Minister of Finance of Algeria); Dr. Soonman Known
(President of Korea Health Industry Development Institute); Mr James P. Scriven (CEO of IDB private
sector institution of the Inter-American Development Bank); Dr. Matshidiso Moeti (WHO Regional
Director for Africa); Dr. John Nkengasong (Director of Africa CDC); and Mr. Amadou Hott (Minister
of Economy, Planning and International Cooperation of Senegal).

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EXECUTIVE SUMMARY
I. This Strategy for Quality Health Infrastructure in Africa 2022-2030 (SQHIA) follows a
request from Governors of the African Development Bank (AfDB or Bank) to define its
role in addressing Africa’s health infrastructure deficits, drawing on its core expertise in
infrastructure development. The request recognises the centrality of health to improving
quality of life for Africans and enabling them to achieve their potential. The strategy also
responds to growing demand from regional member countries (RMCs) for the Bank’s support in
overcoming gaps in national health infrastructure, which have been exposed by COVID-19 and
other health crises.

II. Health challenges across Africa are a cause of significant hardship. Despite recent
progress, child and maternal mortality remain high in many African countries. With just 15% of
the world’s population, Africa accounts for 50% of global deaths from communicable diseases.
Poor health outcomes reflect a lack of access to quality health services: a third of Africans live
more than two hours away from health services, and there are severe shortages in hospital beds,
medical equipment, and drugs. The economic costs of health challenges are severe. It is estimated
that Africa loses $2.4 trillion in annual output due to poor health.

III. Health crises have emerged as a major source of shocks and fragility in Africa. The
COVID-19 pandemic has exposed serious shortcomings in national health systems,
overwhelming surveillance and testing capacity. While Africa enjoyed some initial success in
containing the pandemic, the social and economic costs have been severe, creating Africa’s first
recession in decades and pushing millions of people into poverty. With vaccine distribution slow,
the virus is now resurgent and new variants are emerging – a threat both to Africa and the world.

IV. With its growing population, Africa has large and diverse health infrastructure needs.
Poorer countries and conflict-affected states face the highest rates of communicable disease and
the highest overall disease burden. Other countries face growing challenges with non-
communicable diseases, requiring adaptation of services and infrastructure. Across the continent,
health infrastructure is unevenly distributed, with major gaps in the coverage of rural areas, and
often of poor quality. Only half of primary health care facilities in sub-Saharan Africa have access
to clean water and adequate sanitation and only a third have access to reliable electricity.

V. Africa faces major deficits in financing for health infrastructure. The $4.5 billion in
capital expenditure currently made by Africa governments each year is far below the estimated
$26 billion in annual investment needed to meet evolving health needs over the next decade.
While COVID-19 has highlighted the need for greater investment, the crisis has also left African
countries with severely constrained resources and rising indebtedness. Donor support for health
infrastructure has been declining steadily in recent years, and there are major gaps in the support
available for new secondary and tertiary infrastructure. African countries will therefore need
additional support to meet their health infrastructure, as well as assistance with mobilising
funding from private investments, including from diaspora communities.

VI. The AfDB has the potential to fill an important niche as a health infrastructure
financier, drawing on its core expertise in infrastructure development and working in
partnership with other development partners in support of national health system
strengthening plans. The Bank has a long history of support in health and has scaled up its
assistance in response to recent health crises. It has the capacity to deploy a range of financing
instruments, including private-sector operations and public-private partnerships, to help
overcome the barriers to private investment in the health sector and address the overall financing
gap. The Bank can offer mixed infrastructure investments that connect health facilities to energy,

iv
water and ICT connections, to enable better quality and more innovative health service delivery.
The strategy also sets out how the Bank will build up and consolidate its comparative advantage
in health infrastructure.

VII. Goal. The goal of this strategy is to secure increased access to quality health services for
the people of Africa by 2030, so as to improve their quality of life and promote the achievement
of SDG3 and the African Union’s Agenda 2063 goal on health.

VIII. Objective. The objective of this strategy is to support RMCs in their efforts to accelerate
the development of quality health infrastructure in Africa, and to ensure that individuals and
communities receive the health services they need without financial hardship.

IX. Pillars. The strategy is tightly focused on three categories of health infrastructure that match
the Bank’s comparative advantage, while providing the flexibility to respond to the diverse
needs of RMCs.
1) Primary health care infrastructure for under-served populations, with supporting
infrastructure investment to ensure that facilities are connected to water and sanitation,
energy, transport and communications services.
2) Secondary and tertiary healthcare facilities, involving developing new secondary and
tertiary health care facilities, alongside specialist facilities for cancer, dialysis and pain
management. These investments will be particularly relevant in countries where the
burden of non-communicable diseases is growing rapidly.
3) Diagnostic infrastructure, utilising a range of delivery models, including public-private
collaborations to address serious bottlenecks in efficient and effective diagnosis of
diseases across the continent.
X. The strategy also sets out three cross-cutting themes. First, across all the pillars, the Bank
will support improved ICT connectivity, to strengthen national health information systems and
support innovations in health service delivery, such as tele-medicine and digital health
solutions. Second, it will promote regional collaboration on shared health challenges and the
harmonisation of health policies and regulations, to strengthen regional health markets. Third,
all of the Bank’s health infrastructure investments will be packaged with knowledge work, policy
dialogue and technical assistance, in partnerships with other health sector actors. This support
will focus on promoting effective health financing strategies, including the expansion of health
insurance to secure access for low-income households to ensure that the Bank’s investments are
well-utilised, sustainable and accessible to all on an equitable basis.

XI. The Bank will apply strict selectively criteria and clear principles to guide its health
infrastructure investments. Proposed investments will be screened to ensure they are focused
on the Bank’s areas of comparative advantage and anchored in credible national health system
strengthening strategies, with a clear division of labour with other development partners. The
investments must be clear national priorities and identified as such in Country Strategy Papers.

XII. The Bank will aim to increase its investments in health infrastructure to support this
strategy, using a range of instruments and involving diverse partnerships. The portfolio will
include investment projects, results-based financing, risk-sharing instruments to leverage private
sector resources, debt and equity investments in private companies, and the promotion of
innovative sources of finance, such as diaspora funds.

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XIII. The Bank will undertake a mid-term review of the SQHIA in 2026 to inform an
updated delivery plan for the remaining period of the strategy. The review will explore
progress with implementing the strategy, challenges that have emerged and lessons learnt from
implementation. Based on this analysis, it will identify any adjustments required for delivery
until the end of the strategy in 2030, in order to secure maximum development impact.

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1. INTRODUCTION
1.1 In the Final Communiques from the 2020 and 2021 Annual Meetings of the Bank Group,
the Governors recognised the critical role of quality healthcare infrastructure for the
African continent. They therefore called on the Bank to articulate its evolving role in this
area, in accordance with its comparative advantage alongside other development partners.
In response to that request, the Bank has developed this Strategy for Quality Health
Infrastructure in Africa 2022-2030 (SQHIA).
1.2 The importance of quality health services, both as a development goal in its own right
and a foundation for achieving inclusive growth and other development goals, is
widely recognised. As set out in the Bank’s proposed Strategy to Improve the Quality of
Life for the People of Africa, access to quality healthcare is essential to the ability of
Africa’s population to thrive and reach their full potential. The Bank is committed to
promoting access to quality health services, in accordance with aspiration 1.3 of the African
Union’s Agenda 2063 for a healthy and well-nourished citizenry, and the UN Sustainable
Development Goal No. 3 on good health and well-being. Addressing health challenges can
also make a vital contribution to progress across the High 5s,1 given that poor health
undermines economic productivity across all sectors and that disease has been estimated to
cost Africa $2.4 trillion annually.2 It has been estimated that if known health interventions
were applied across Africa in order to reduce the disease burden, GDP growth could be
increased by 0.5 percentage points per annum across the continent over the next 20 years.3
1.3 The COVID-19 pandemic and other epidemics in recent years have highlighted major
deficits in national health systems and related infrastructure across Africa. Only 51%
of primary health facilities in sub-Saharan Africa have access to basic water and sanitation
services,4 and Africa has only 1.3 hospital beds per 1,000 people (compared to 2.1 in Latin
America and 6.1 in Europe).5 These gaps underlie Africa’s vulnerability to repeated health
crises and consequent development reversals. The severity of the pandemic and the
economic crisis it has triggered have created a unique opportunity to address longstanding
deficits in health infrastructure and services. However, in the wake of the pandemic,
African countries also face sharply constrained fiscal resources and rising debt levels.
Access to finance for health infrastructure will be a significant constraint on the
development of the health system in the coming years.
1.4 Building on a long history of health support, the AfDB has responded to recent health
crises by deepening its support for health infrastructure. The Bank invested
approximately $5 billion in health operations over the period 1975 to 2020, with the rate of
investment peaking in the 1990s. However, after 2000 the Bank’s strategic focus changed
and its investments in health were scaled back. In recent years, the Bank has faced a strong
demand for health support from RMCs, particularly during health crises. As a result, the
Bank has provided significant support to public-health emergencies, including
approximately $222 million for the Ebola response1 and approximately $4 billion for
COVID-19 health related operations2. However, this engagement has taken place in an ad
hoc way, without a clear strategic plan or a tight enough focus on the Bank’s areas of
comparative advantage, such as health infrastructure.

1
This includes $150 million budget support for Côte d’Ivoire, Guinea, Liberia and Sierra Leone.
2
This includes the COVID-19 crisis response budget operations, which focused on health, social protection and
economic policy measures. Specifically, under the health component, the budget support operations aimed at
strengthening policy and regulatory measures to increase testing, tracing, treatment and training and protection of
front-line health workers. However, it is difficult to determine how much of the funding was allocated to finance
these results.

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1.5 The SQHIA sets out a strategic framework for the Bank’s engagement in the
development of health infrastructure. The Bank defines health infrastructure as physical
structures and supporting systems, particularly finance, needed to deliver a continuum of
health promotion, preventative, curative, rehabilitative and palliative services appropriate
to the needs of the target population. It includes healthcare facilities at all levels, diagnostic
facilities and non-clinical infrastructure needed for the effective operation of healthcare
services (particularly water and sanitation, electricity and digital connectivity). The Bank
will not offer broader support for health system strengthening, which is the comparative
advantage of other development partners. Furthermore, within the area of health
infrastructure, it will not invest in workforce training institutions, logistics infrastructure,
and research & development facilities. The pharmaceutical sector is subject to a separate
strategy currently being developed by the Bank.
1.6 The SQHIA is based firmly on the Bank’s comparative advantage – in particular, its
role as an infrastructure financier – working alongside other development partners
specialised in other aspects of health system strengthening. It defines a specific niche
for the Bank in addressing infrastructure bottlenecks within national health system
strengthening plans. It sets out clear criteria for identifying strategic projects that match
both the Bank’s comparative advantage and the diverse needs of RMCs. The criteria specify
that the Bank’s investments in health infrastructure must form part of credible national
health systems strengthening strategies, to ensure that other aspects of developing quality
health services, including health policies, financing arrangements and workforce
development, are pursued in parallel. This will minimize the risk of the Bank investing in
non-functional health facilities. The strategy sets out the range of financing instruments
that the Bank will employ, including non-sovereign operations and risk-sharing instruments
to promote public-private partnerships (PPPs). The strategy provides that the Bank’s
investments in health infrastructure will be accompanied by policy dialogue and technical
and knowledge advisory assistance to help RMCs address health financing challenges,
develop innovative strategies for expanding services, make good use of emerging
technologies, and promote regional harmonization in relation to health technologies and
workforce qualifications. It sets out an action plan for building the Bank’s comparative
advantage in health infrastructure over the life of the strategy, taking a ‘One Bank’
approach to delivery.
1.7 The objective of the strategy is to support RMCs to accelerate the development of
quality health infrastructure and ensure that all individuals and communities receive
the health services they need without financial hardship. The strategy is closely aligned
with the Bank’s Ten-Year Strategy and other |High 5 priority areas, in particular ‘Improving
the Quality of Life for the People of Africa’. It sets out how quality infrastructure
investments can contribute to other High 5 priorities, and how investments in other
infrastructure areas, including water and sanitation, energy, transport and ICT, can
contribute to strengthening national health systems.
1.8 The strategy draws on the outcomes of an extensive consultation with external
stakeholders, who endorsed the strategy and its relevance to Africa’s needs. The
consultations included Ministers of Health and senior health officials, Regional Economic
Communities, the private sector, civil society and other development partners. The
outcomes are summarised in Annex 9 and are incorporated throughout the strategy.
2. THE CASE FOR INVESTING IN HEALTH INFRASTRUCTURE IN AFRICA
Significant and diversifying health needs across Africa
2.1 The disease burden in Africa remains high, with significant unmet health needs. While
Africa accounts for just 15% of the world’s population, it bears 24% of the global disease

2
 burden and experiences 50% of global deaths from communicable diseases.6 Despite recent
progress, under-5 mortality (82/1,000 live births) and maternal mortality (533/100,000)
remain high in sub-Saharan Africa and average life expectancy is just 62 years.7 In 2016,
600 million life-years were lost due to disability and poor health across Africa.8
2.2 African countries face growing and increasingly diverse health challenges over the
next decade. Generally, as countries develop, the burden of communicable diseases
declines while non-communicable diseases (NCDs) increase. Health services and
infrastructure need to adapt accordingly. African countries are at different points on this
trajectory, giving them diverse health needs (see Figure 1). Over the decade to 2030, 17
African countries (Archetype A, see figure 1 below) – mostly fragile contexts and Least
Developed Countries – will face the highest overall disease burden. This will be driven by
a dual burden of continuing high levels of communicable disease – especially maternal and
neonatal disorders and childhood-cluster diseases – and growing rates of NCDs. In contrast,
13 African countries (Archetype C, see Figure 1 below) – a mix of Lower and Upper
Middle-Income Countries – will face a lower overall disease burden, but must adapt their
health services to new challenges, related predominantly to non-communicable diseases
(NCDs). These include cardiovascular diseases (17% of the total disease burden), mental
and substance use disorders (12%), and musculoskeletal disorders (9%). In addition, a
group of 24 African countries (Archetype B countries, see figure 1 below) – a mix of Low
and Middle Income Countries, nine of which are in situations of fragility – will face a
medium disease burden, characterised by falling levels of communicable disease and
growing levels of NCDs. During the period 2021-30, overall health needs across Africa are
expected to grow by 23%.
Figure 1: Africa’s diverse health needs

African Countries can be classified into three disease-burden groups or archetypes, based on
projected trends.9 These archetypes each face different health challenges and infrastructural needs:
97% of ADF countries fall into Archetypes A and B, while most ADB countries are in Archetype C.
Archetype A Archetype B Archetype C
Communicable Diseases (CD) NCDs steadily increase (46% vs NCDs dominate overall burden
account for largest share of 42% of projected overall burden (74%) and CDs decrease (-45%)
burden in 2030 (>50%) in 2030 and 2016 respectively) Decrease in injuries (-8%)
Simultaneous rapid growth in Steady decline in CDs Total disease burden of 24,045
NCDs and injuries (+24% and (-51% by 2030) and decrease in DALYs/100k people by 2030
+46% by 2030) injuries (-8% by 2030)
Highest total disease burden at Total disease burden of 32,462
68,667 DALYs/100k people by DALYs/100k people by 2030
2030
Angola, Burkina Faso, Chad, Central Benin, Burundi, Cameroon, Comoros, Algeria, Botswana, Cape Verde, Djibouti,
African Republic, Côte d’Ivoire, D.R. Congo, Eswatini, Ethiopia, Equatorial Egypt, Gabon, Libya, Mauritius, Morocco,
Congo, Eritrea, Guinea, Guinea-Bissau, Guinea, Gambia, Ghana, Kenya, Namibia, Seychelles, South Africa and
Lesotho, Liberia, Mali, Mozambique, Madagascar, Malawi, Mauritania, Niger, Tunisia
Nigeria, Sierra Leone, South Sudan and Rwanda, Sao Tome & Principe, Senegal, Population: 310 million by 2030
Zimbabwe Somalia, Sudan, Tanzania, Togo, Uganda,
Population: 660 million by 2030 Zambia
Population: 718 million by 2030

Demographic changes and health crises drive growing health challenges across Africa
2.3 Africa’s evolving demand for health services is driven by multiple interconnected
trends. Growing and ageing populations will increase the overall number of people seeking
healthcare, as by 2030 Africa’s population is projected to grow to 1.68 billion (a 42%
increase compared to 2015), with the population over 60 years of age growing to 105
million (a 64% increase compared to 2015).10 Income growth, which has been interrupted

3
 by the COVID-19 pandemic, but which is expected to resume in the coming years,11 will
make healthcare services more affordable. Furthermore, Africa’s urban population is
expected to grow to 770 million by 2030 (an increase of almost 300 million compared to
2015)12, resulting in a greater need for health-service delivery infrastructure in urban areas,
as well as higher NCD risk factors such as poor diet and exposure to air pollution.
2.4 Health crises have emerged as a major source of shocks and fragility in Africa. Over
the recent decades, the frequency of health crises, such as the Ebola Virus Disease, has
increased. Dengue, cholera, Lassa fever, yellow fever and bacterial meningitis, amongst
other diseases, are resurgent across the continent.13 Since 2000, multiple outbreaks of
yellow fever, Marburg haemorrhagic fever, bubonic plague, measles, cholera and Ebola
have been reported. Since 2012, Ebola outbreaks have become yearly episodes in the
Democratic Republic of Congo (DRC). In 2014, the World Bank estimated foregone
economic growth from the West African Ebola epidemic at $33 billion across the three
worst-affected countries.14
COVID-19 has created new challenges
2.5 Most recently, the COVID-19 pandemic has exposed serious weaknesses in Africa’s
health systems and access to vaccines, which may have global implications. While
African countries enjoyed early successes in containing the pandemic, it has illustrated how
quickly Africa’s surveillance capacity and diagnostic infrastructure can be overwhelmed
by a health crisis. Although the direct health impact of COVID-19 across Africa to date has
been relatively modest, the emergence of new strains of the virus creates significant risks
that these impacts will grow in the coming months. The limited access that African
countries have had to global vaccine supplies heightens these risks and means that Africa
could become a source of new viral strains. The COVID-19 pandemic is also having
significant indirect health impacts, due to disruption to health services and emerging co-
morbidities. Interruptions in bed net distribution and related services may increase malaria
cases by a third across high-burden low- and middle-income countries over the period to
2025.15 Mass immunisation programmes for childhood diseases have been put on hold in
at least 25 African countries, leaving millions of children unprotected from diseases such
as measles, polio, yellow fever and diphtheria.16 There are also concerns that conditions
such as HIV/AIDS, tuberculosis, malnutrition and bacterial and respiratory infections,
which are a major challenge in Africa, may create comorbidities that increase the risks from
COVID-19 infection.17 These cases illustrate that, as COVID-19 becomes endemic, it will
increasingly combine with the biological and social challenges around other communicable
diseases, giving rise to potent ‘syndemics’ which increase the overall burden of these
diseases.18
2.6 The COVID-19 pandemic has also further illustrated the economic and social shocks
that can result from health crises. Measures taken to control the COVID-19 pandemic
have caused Africa’s first recession in more than two decades, reduced the incomes of 150
million workers and may push 30 million additional people into extreme poverty. Although
Africa’s economy is predicted to return to growth in 2021,19 this recovery is expected to be
fragile, due to recurrent waves of the pandemic and limited access to vaccines, which is
expected to suppress investment in key sectors.20 The pandemic has also caused significant
disruption to education and skills development across Africa, creating what the World Bank
has called “the worst crisis to education and learning globally in a century”.21 The people
most affected by the economic and social impacts of the pandemic are those with lower
levels of education, fewer assets and who depend in informal jobs.22 This suggests that the
pandemic has led to worsening levels of inequality and marginalisation for large numbers
of people across Africa.

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A range of factors are constraining health systems development
2.7 A wide range of factors are acting as constraints on health development, including
weak health infrastructure. Effective national health systems incorporate a range of
‘building-blocks’, including a health workforce, access to essential medicines, service
delivery capacity, health information systems, financing, and leadership and governance.23
Many African countries face constraints across all these areas: Archetype A and B countries
have only have a fifth of the minimum required number of physicians,24 and many countries
have limited availability of priority medicines for women and children.25 Constraints
relating to physical health infrastructure capacity are also significant. Africa currently has
only 1.3 hospital beds per 1,000 people (compared to 6.1 in Europe)26 and only one
intensive care bed for every 100,000 people27 (compared to seven in India28). Around 30%
of Africans live more than two hours from essential health services.29 Only half of the
primary health facilities in sub-Saharan Africa have basic water and sanitation services30
and only one third have access to reliable electricity.31 As revealed during the COVID-19
pandemic, diagnostic equipment is in short supply and poorly maintained across the
continent, with only two countries able to perform COVID-19 laboratory diagnostic at the
beginning of the pandemic.32 Wider constraints related to diagnostic capacity are illustrated
by the fact that Africa has only 0.7 Magnetic Resonance Imaging (MRI) scanners for every
1,000,000 of its population (compared to 4.8 in China and 37 in the USA),33 demonstrating
the limited readiness of many African laboratories to carry out basic diagnostic tests34 and
the low density of laboratory health workers in Africa.35
Health infrastructure constraints are significant and will worsen
2.8 Over the next decade, as health challenges grow and evolve, these infrastructural
constraints will become even more pronounced and diverse across Africa. Based on current
investments trajectories and projected health needs to 2030, the Archetype A countries (see
Figure 1) are likely to have adequate numbers of primary healthcare facilities (albeit with
accessibility an ongoing challenge), but only just over half of the required number of beds
in secondary health facilities and MRI scanners, and only 15% of the required intensive
care unit (ICU) capacity. Archetype B countries will face constraints across all levels of
health services, with just under three quarters of required primary care capacity, less than
half of the required number of beds in secondary health facilities, just 15% of the required
ICU capacity and 60% of required MRI scanners. Archetype C countries are expected to
have adequate primary care capacity, but just 70% of the required number of beds in
secondary health facilities, only a quarter of required ICU capacity and a little over 40% of
required MRI scanners.36 There is also underutilisation of health infrastructure across many
African countries, due to accessibility issues and limited health insurance coverage. As a
result, the risk of death after surgery in Africa is double the global average 37 and accuracy
in applying essential diagnostic tests is less than 50%.38
2.9 Investment in critical health infrastructure is falling well behind projected needs.
Current expenditure on health in sub-Saharan African countries averaged 5.1% of GDP in
2018 (compared to 6.7% in East Asia and the Pacific, and 8% in Latin America and the
Caribbean), a figure which has barely changed over the last two decades.39 Government
health expenditures represent only 1.9% of GDP in Sub-Saharan Africa, far below the target
of 5% suggested by UNECA and low compared to East Asia and the Pacific (4.4%) and
Latin America and the Caribbean (4.1%). For the Archetype A and B countries, public
spending on health is currently just $24 and $22 per capita respectively,40 compared to the
$70 minimum level41 required for universal coverage of basic health services. As a result
of these shortfalls, out-of-pocket expenditure constitutes around 40% of health expenditure
on average across these countries,42 creating a significant drain on family incomes and
making catastrophic health expenditures a major cause of hardship. Furthermore, only

5
 around 6% of total public health spending in Africa goes towards developing health
infrastructure. By comparison, many Asian and Latin American countries allocate more
than 20% of government health expenditure to infrastructure.43 The combination of
underinvestment, high and increasing disease burdens and high population growth means
that infrastructure shortages are acute. The $4.5 billion44 that African governments
currently invest in public health capital expenditure is far below the estimated $26 billion45
annual investment in new health infrastructure needed to meet evolving health needs over
the next decade. This is in addition to the significant investment required for the
maintenance and upgrading of existing health infrastructure.
Financing gaps are growing, and new sources of finance will be required
2.10 Weak public finances in Africa will make mobilizing investments for health
infrastructure challenging in the coming years. The economic impacts and spending
demands resulting from the pandemic have led to a doubling in fiscal deficits, while the
average debt-to-GDP has climbed by 10 to 15 percentage points (to 70%) across Africa.46
Many African countries will continue to face economic uncertainty for some time, given
the ongoing effects of the pandemic. As a result, African governments now have
significantly lower capacity to address health infrastructure deficits in the short to medium
term.
Box 1 : Use of incentives to stimulate diaspora investment in the Indian health sector

Since the late 1980s, the Indian diaspora has been critical to the growth of India’s healthcare
infrastructure through foreign direct investments.47 The diaspora has supported the establishment of some
of India’s top private hospitals, the development of high-quality specialty healthcare and the procurement
of modern medical equipment and technology.48
The Government of India has utilised a number of policy incentives in order to attract investment from
the diaspora, including:
• Automatic approval for hospitals and diagnostic centres to receive up to 100% foreign equity
participation from diaspora investors
• Removal of restrictions on equity shares held by diaspora investors in Small-Scale Industries in
the health sector
• Exemption from import duties for products imported by diaspora operators of health facilities if
at least 25% of patients are offered free treatment.
In addition, investments from the Indian diaspora have been promoted by a wider set of incentives
applicable to all private investors in the health sector, including exempting healthcare education and
training services from service tax, tax holidays for investors in hospitals with more than 50 beds and tax
reductions for investors in large facilities in rural areas.

2.11Filling the financing gap for health infrastructure will require mobilizing finances
from the private sector, development finance institutions and diaspora groups. Across
Africa, only 10-20%49 of investment in health service delivery infrastructure is currently
mobilized by the private sector, due largely to high levels of investment risk. The limited
coverage of health insurance and the dominance of out-of-pocket expenditure in health
financing also makes it more difficult for investors to secure a financial return. As a result,
private sector investments in health infrastructure have been concentrated in brownfield
investment to expand existing hospitals. Development partners, including private
foundations, also contribute to the financing of health infrastructure, although grant aid for
health-related capital investment from OECD countries has fallen by 6% annually since
2014.50 This has focused predominantly on greenfield investments in primary healthcare.
External investments in new secondary and tertiary health facilities have been led mainly

6
 by Development Finance Institutions (DFIs), especially the IFC and bilateral DFIs.
Foundations such as the Bill and Melinda Gates are projected to play a growing role in the
financing of health services in Africa and will be key partners for the Bank.
2.12There is also potential for mobilizing funding from diaspora communities and
associations, either directly or through instruments such as diaspora bonds. Since the
late 1980s, India has used fiscal and non-fiscal incentives (see box 1 below) to stimulate
diaspora investment in health services, and nine of the top fifteen hospitals in India have
been set up through such investments. The Ethiopia Diaspora Trust Fund has to date raised
nearly $8 million and has supported healthcare projects, including most recently in response
to the COVID-19 pandemic. Social bonds – which pay out to investors on the basis of social
impacts – could also provide a mechanism for attracting health sector investment, although
evidence of their potential in developing countries is so far limited.51 So far, such
instruments in Africa have been small in scale, but the Bank will explore whether they offer
a basis for replication at a larger scale.
Expanding access to quality health services
2.13African countries will need to take a range of measures to ensure that quality health
services are accessible and affordable, including to poorer communities. These include
investing in infrastructure for last-mile delivery by expanding the coverage of primary
health care facilities, particularly to remote and conflict-affected areas, raising the quality
of basic health services by providing access to water, sanitation and power connections for
primary health care facilities, and increasing the availability of secondary and tertiary
facilities and specialised health care and diagnostic centres. Improving access for the poor
also requires expanding the coverage of social protection and health insurance, and
innovations in health service delivery, including through e-health in accordance with the
WHO’s strategy of Universal Health Coverage (UHC) which states that all people should have
access to the health services they need, when and where they need them, without financial
hardship.
2.14 Health insurance is emerging as a key tool on the African continent for promoting
inclusive access to health services, with support from governments and development
partners. National health insurance schemes remain in their infancy in most countries, with
only 30% of archetype A countries and half of archetype B and C countries having coverage
rates above 10%.52 Poor and marginalised groups are often excluded from health insurance
schemes, with a recent study finding that women in sub-Saharan Africa with no formal
education were 78% less likely to be covered by health insurance than those with higher
levels of education.53 An example of a health insurance scheme that has succeeded in
widening access to health services is Rwanda’s subsidized health insurance scheme,
Mutuelle, launched in 2004. This scheme was reformed in 2011 to introduce stratified
premiums linked to income, with the poorest households receiving free coverage, a model
that other African countries can learn from and customise to their needs. Firms such as
MicroEnsure are also demonstrating the potential for health insurance services for people
living on less than $4 a day, with premiums paid through mobile phone-based banking. The
AfDB’s work in this area has included providing more than $450 million in support over
the last 15 years to a social health insurance scheme in Morocco, as well as support for
other social protection schemes in Côte d'Ivoire and Senegal. In addition to helping widen
access to healthcare, health insurance schemes also stimulate demand for health services,
which in turn can improve the utilisation of health infrastructure.
2.15 Ensuring all individuals and communities receive health services will also require
innovations in health service delivery, with the private sector playing an important
role. A wide range of actors currently provide health services in Africa, including
commercial, not-for-profit and faith-based providers. While government is indispensable

7
 as regulator and coordinator of the sector, private actors will be key to the expansion of
coverage. Diverse models of public-private partnership are emerging, from commercial
providers offering health services directly to the public, to governments purchasing
specialized services, such as diagnostics, transport, or medical waste disposal, from private
firms.54 The private sector will also be key to expanding the last-mile delivery of health
services through digital infrastructure such as mobile telephone facilities and telemedicine,
and for helping to finance efforts to achieve health access for all over the long-term. For
example, ThinkMD is a company that provides health advice utilizing physician-based
artificial intelligence technology, which can be accessed through mobile phones. Another
example is M-SCAN, in Uganda, who manufacture, sell and maintain mobile ultrasound
probes which can be used in resource-limited and remote settings to support early detection
and management of risk factors of maternal and neonatal mortality.
Regional cooperation in specialist health services will be important
2.16 Expanding access to specialist health services will be an important element in
building robust national health systems. Specialist tertiary facilities will increase the
supply of highly skilled health professionals and promote excellence in service delivery.
Increasingly, such specialist services will be organised on a sub-regional basis, drawing on
telemedicine and mobile service to expand reach.
2.17Regional approaches to health policy and regulation will help to promote
collaborative and coordinated responses to Africa’s health challenges. Differences in
health policy and regulation across African countries is hindering the movement of health
workers, the spread of health technologies and efforts to develop common solution to health
challenges across the region. It is therefore vital that efforts are made to improve the
harmonization of health policy and regulation across Africa, and to further develop
collaboration in addressing common challenges.
2.18The Bank is already supporting the development of centres of excellence for specialist
health services, and this will be a continuing focus. An example of our work in this area
is our support for the first phase of the Centre of Excellence for Skills and Tertiary
Education in Biomedical Sciences Project. This project supports the creation of a network
of Centres of Excellence across East Africa, including a focus on nephrology and urology
in Kenya, oncology in Uganda, cardiovascular health in Tanzania, and biomedical
engineering and eHealth in Rwanda. This project aims to contribute to the development of
a skilled workforce in biomedical sciences to meet East African Community (EAC) labour
market needs and support the implementation of regional labour market protocols. It also
supports the standardisation of medical qualifications across the region, in support of labour
mobility.
3. AFDB’S COMPARATIVE ADVANTAGE ON HEALTH INFRASTRUCTURE
3.1 The Bank has a significant track record on health, totalling around US$5 billion in
investment since 1975. Of this, approximately 40% went towards health infrastructure,
across 131 projects (Annex 8). The early focus was on primary care facilities, but more
recently RMC demand has included secondary and tertiary facilities, most notably in East
Africa. Examples of current projects within the scope of the Strategy include:
- Last-mile expansion of primary healthcare: In Sudan, the Bank is helping expand
primary healthcare in underserved communities, to reduce the risk of people being
pushed into extreme poverty by catastrophic health expenditure through the Building
Capacity for Inclusive service Delivery Project which has been in operation since 2015.
The Bank is also supporting the construction and rehabilitation of primary health
facilities in Morocco, Côte d’Ivoire and Senegal.

8
 - Secondary and tertiary health infrastructure: In Uganda, the Bank through the
Improvement of Health Services Delivery at Mulago Hospital and in the City of
Kampala Project (MKCCAP) 2012 – 2019 established two new (each 170 beds) fully
equipped national referral hospitals, expanding access to health care services for the
Kampala Metropolitan Area. A third multi-specialty hospital (Mulago), which is the
major national referral hospital, was also extensively rehabilitated and equipped; as part
of the changes, the intensive care unit was enlarged from 7 beds to 41 beds, of which
27 are adult beds and 14 are pediatric beds. The mortuary was expanded from 16 to 160
slots; and, the number of operating theatres were increased from 7 to 22. The ongoing
East Africa’s Centres of Excellence for Skills and Tertiary Education in Biomedical
Sciences Project Phase 1 is supporting the creation of a network of Centers of
Excellence (CoEs) in biomedical sciences and engineering - Nephrology and Urology
in Kenya, Oncology in Uganda, Cardiovascular in Tanzania and Biomedical
Engineering and eHealth in Rwanda.
3.2 The Bank’s comparative advantage on health infrastructure also rests on its wider
expertise in infrastructure development. Over the past decade, the Bank has dedicated
around half of its resources to infrastructure development, with $40 billion in commitments,
making it the second-largest financier of infrastructure in Africa. Through these operations,
the Bank has built up extensive expertise in developing infrastructure projects, together
with technical assistance to facilitate all stages of the investment process, which is directly
applicable to investing in the health sector.
3.3 The Bank has the expertise to help RMCs attract private investment into
infrastructure development. The Bank offers expertise in infrastructure PPPs and the
ability to deploy a mix of financing instruments, including non-sovereign operations and
de-risking instruments to leverage private sector investments. As of September 2019, the
Bank had a portfolio of $1.5 billion in investments into infrastructure PPPs, through which
it has built up considerable expertise in PPP regulatory frameworks and investment design.
Through its non-sovereign operations, it can invest in private health service provision, in
areas such as diagnostics, transport and waste disposal that are often outsourced. The
Bank’s experience in SME financing is also an important factor, given the role of SMEs in
delivering private healthcare. The Bank can also harness the experience of its
Industrialization team in incorporating new technology into its infrastructure investments,
to enable new ways of delivering health services.
3.4 The Bank is uniquely placed to deliver health infrastructure in a package with other
supporting infrastructure investments. At present, only half of the primary healthcare
facilities in sub-Saharan Africa have clean water and only a third have reliable access to
electricity. This presents a major constraint on the quality of healthcare that can be provided
through these facilities. It also inhibits the distribution of vaccines and medicines that
require cold chain storage. The Bank can package its health infrastructure investments to
include support for water and sanitation, energy, transport, and digital connectivity
infrastructure – all areas where the Bank already has substantial portfolios. WASH
infrastructure is particularly important in the context of the COVID-19 pandemic, to reduce
the risk of health facilities becoming vectors of transmission. Mixed infrastructure
investments will be essential to ensuring ‘last-mile’ delivery of health services in remote
and low-income areas. The Bank is also in a position to support digital connectivity for
existing health facilities, in support of improved health information systems and
telemedicine.
The Bank can play a valuable role in reducing health infrastructure bottlenecks, working
alongside other development partners to provide niche support for national health system
strengthening strategies. Health system strengthening is a multi-dimensional challenge, and

9
 investments in infrastructure must be accompanied by investment and capacity development
across a range of fronts, including a health workforce, essential medicines, service delivery
capacity, financing, leadership and governance.55 The Bank will only invest in health
infrastructure projects that form part of credible national health system strengthening strategies,
and where it supports interventions that complement those of other development partners. This
will be an explicit criterion for project selection, to minimize the risk of investing in facilities
that remain unused for lack of equipment, personnel or recurrent budgets. This criterion will
also ensure the sustainability of Bank investments.
Figure 2: Focus areas for development partners in African health infrastructure

3.6 The Bank’s offer on quality health infrastructure is complementary to the efforts of
other development partners in the health sector. A mapping of development finance
flows into African health infrastructure in 2010-2018 (see Figure 2 above, and Annex 5)
showed a significant emphasis on bricks and mortar infrastructure in support of primary
healthcare facilities (from bilateral and multilateral development agencies) and brownfield
secondary healthcare facilities (from private investors and development finance institutions
such as IFC). In contrast, there are fewer actors engaged on investing in greenfield
secondary and tertiary healthcare facilities, brownfield investments to upgrade or expand
infrastructure in the public sector and on connectivity and innovative healthcare solutions.
There has also been a limited emphasis on delivering complementary support to develop

10
 health systems strengthening and financing strategies, and to ensuring alignment with these
strategies. These are all areas in which the Bank has extensive or emergent comparative
advantage, and in which it can add significant value. In addition, the Bank is a leading actor
in providing infrastructure and other forms of support to countries in situations of fragility,
as illustrated by its recent support to construct South Sudan’s first oxygen manufacturing
plant and the rehabilitation of four health facilities in response to demands emerging as a
result of the COVID-19 pandemic (see Annex 4 for more information).
3.7 The Bank will leverage its extensive experience of combining infrastructure financing
with complementary support to promote the sustainability of investments and
equitable access. The Bank’s infrastructure investments are accompanied by a package of
complementary support measures (typically utilising 10%-25% of financing56), such as
policy dialogue, technical assistance and knowledge products. This additional support aims
to help create an enabling environment for successful project delivery, to promote effective
and equitable utilisation of the infrastructure, to ensure that the investments benefit the poor
and are sustained into the future. For example, Bank policy dialogue can help to mobilise
domestic finance to sustain infrastructure, its knowledge support can help to identify and
promote approaches for expanding access to health services, and its technical assistance
can help to strengthen capacity for managing PPPs. In recent years, the Bank has provided
financing and technical assistance to help expand social protection in Côte d'Ivoire,
Morocco and Senegal, and the Bank-hosted African Legal Support Facility has been
providing advice to African governments in negotiating complex commercial transactions
and to structure PPP contracts.

4. LESSONS LEARNED
4.1 The strategy is informed by a number of lessons learned from the Bank’s previous
experience in the sector. Firstly, it is important to note that the Bank’s experience is that
projects integrating transport, education, health, water & sanitation and economic
infrastructure tend to bring better results for beneficiaries, by ensuring the full spectrum of
needs and drivers of sustainable impact are addressed. Secondly, a key challenge with
previous Bank health projects has been their quality at entry, and therefore particular
emphasis needs to be placed on the preparatory phase, including undertaking feasibility
studies and robust economic and sector analysis. Thirdly, analysis of the Bank’s operations
has illustrated the importance of reducing negative environmental impacts, by undertaking
and integrating the design requirements emerging from in-depth environmental and social
impact assessments. Finally, it is clear that securing the ownership, commitment and
involvement of partner governments is particularly important, and this should include an
emphasis on ensuring that counterparts commit maintenance and recurrent funding so as to
promote the sustainability of projects.
4.2 A range of important lessons are also apparent from the experiences of other
financiers of health infrastructure. These experiences suggest that it is important to
ensure that adequate resources and partnerships are leveraged in order to secure sustainable
impact at scale. This will be helped by financing a smaller number of larger projects,
developing co-financing and knowledge partnerships with multilateral institutions,
leveraging financing from the private sector and ensuring that governments play the role of
regulators, licensers and quality controllers across the health sector. Past experience points
to the importance of strengthening project execution and monitoring through promoting
improved governance in the health sector. This can be promoted through facilitating the
efforts of member countries to leverage sector financing, shape health reforms and lead
policy dialogue, promoting the participation of all relevant stakeholders in the design of
programs, and developing robust results-based management, monitoring and evaluation

11
 systems in the health sector. Finally, learning from other financiers emphasises the
importance of ensuring efforts are made to strengthen the enablers of effective utilisation
of health infrastructure, especially affordability, human resource capacity and finance for
recurrent expenditures.
4.3 It is also useful to draw on learning from global innovations in health service delivery,
which can be adapted to the African context in order to improve the efficiency and
effectiveness of infrastructure investments. A key lesson here is that digital technologies
have begun to alter how healthcare is delivered and have the potential for disruptive change.
For example, enhanced connectivity between patients and providers can ensure better and
more affordable access to care for larger numbers of patients, especially those living in
remote areas. Advances in medical technology are delivering better quality and outcomes
of care and offering a wider range of treatment options. New provider payment mechanisms
can help to promote equitable access to healthcare by creating incentives to improve health
service delivery, quality and efficiency. Finally, it is relevant to highlight how new service
delivery models – such as e-health services and the aggregation of patient procedures – are
emerging which can help to improve value for money and efficiency.
5. OBJECTIVES AND STRATEGIC APPROACH
Goal and objective
5.1 Goal. The goal of the SQHIA is to secure increased access to quality health services for the
people of Africa by 2030, in order to improve the quality of life for the people of Africa
and promote the achievement of SDG3 (to ensure health lives and promote well-being for
all at all ages) and the African Union’s Agenda 2063 goal on health (to ensure Africa’s
citizens are healthy and well-nourished). Good health is indispensable to the quality of life
and a foundation for improving labour productivity, inclusive growth and many other
development goals. Emphasis will be placed on reaching and improving access for the poor
and vulnerable populations.
5.2 Objective. The objective of this strategy is to support regional member countries in their
efforts to accelerate the development of quality health infrastructure in Africa, and to
contribute to their efforts to ensure that all individuals and communities receive the health
services they need without suffering financial hardship. Achieving this objective will be
vital to efforts to achieve the overall goal of this strategy.
Pillars
5.3 Pillars. The SQHIA is tightly focused on three categories of health infrastructure that will
help to deliver the overall objective of this strategy and match the Bank’s comparative
advantage, while providing the flexibility to respond to the diverse needs of RMCs across
the three archetypes (see Figure 1). Details of the content of each pillar are provided in
Section 6.
i) Pillar 1: Primary health care infrastructure. Under this pillar, the Bank will address
last-mile infrastructure gaps and undertake mixed infrastructure investments. This will
involve constructing health facilities for under-served populations, with supporting
infrastructure investment to ensure that facilities have access to clean water and
sanitation, energy, and IT connections, for quality health services.
ii) Pillar 2: Secondary and tertiary healthcare facilities. The Bank will invest in
developing secondary and tertiary health care facilities, alongside specialist facilities
for cancer, dialysis, and pain management. These investments will be particularly
relevant in countries where the burden of non-communicable diseases is growing
rapidly. The flagship projects may include regional centres of excellence. This pillar

12
 addresses a clear gap in current health finance flows in respect of greenfield investments
in new health facilities.
iii) Pillar 3: Diagnostic infrastructure. This pillar will help to address major deficits in
Africa’s diagnostic infrastructure and may include a range of delivery models, including
outsourcing to the private sector.
5.4 Cross-cutting themes. The Bank will integrate three cross-cutting objectives into its support
across all three pillars.
i) Connectivity for innovative health solutions. The Bank will invest in ICT
connectivity, to support the development of improved health information systems and
innovations in health service delivery, such as mobile services, tele-medicine and other
digital health solutions.
ii) Promoting regional collaboration on health challenges. The Bank will support
efforts to deepen the harmonization of health policies and regulations across Africa and
promote common approaches to addressing the regions’ health challenges.
iii) Knowledge work, policy dialogue, and technical assistance. All investments in
health infrastructure will be packaged with policy dialogue and technical assistance
(TA), to ensure that the capital investments are anchored in clear strategies and
financing frameworks and contribute to equitable and sustainable health services. The
Bank will develop a programme of knowledge work to inform its policy dialogue and
cultivate relationships with external partners able to offer specialized technical support.
5.5 Scale of investment. During the 1990s, the Bank invested approximately $75 million
annually. Adjusted for inflation, this would be equivalent to $300 million per year at current
prices, or 5% of the Bank’s current lending portfolio. It is anticipated that the Bank’s health
infrastructure investments will be catalytic, and its portfolio will progressively scale up
towards that historical level over the life of the strategy. A strong pipeline is already in
place for the 2022-2024 period, including non-sovereign operations through debt financing
of hospitals in Kenya, Egypt and other North African countries. However, no financial
targets are included in the SQHIA, given the demand-driven nature of the portfolio.
Figure 3: Theory of Change

13
6. PRIORITIES UNDER THE STRATEGIC PILLARS
6.1 This section of the strategy sets out in more detail how the Bank will identify strategic
investments within each of its four strategic pillars, and how it will combine investment
projects with policy dialogue and technical support.
Pillar 1: Primary health care infrastructure
6.2 The Bank will finance primary healthcare infrastructure expansion, particularly in
fragile contexts, LICs and small island states, to reduce the last-mile access gap. These
facilities will increase equitable access to health services among remote populations and
vulnerable groups, and also promote gender equity. The Bank’s diagnostic work shows
that, while on average the ratio of primary health care (PHC) facilities to population is
comparable to other regions, there are major discrepancies between and within countries.
Around 30% of the African population still lives more than two hours travel away from
basic health services.57 Countries in Archetype A have the lowest access rates, despite
adequate overall PHC facility density, due to sub-optimal geographical distribution.
Furthermore, many PHCs lack access to power, clean water and sanitation, and are
therefore unable to offer services of an acceptable quality.
6.3 The Bank will combine brick-and-mortar investments in primary healthcare (PHC)
with a significant emphasis on supporting non-clinical infrastructure. Alongside support
for building new primary healthcare facilities, the Bank will support both new and existing
health facilities to connect to water and sanitation services, electricity connections, and digital
services. This is an area where the Bank has a clear comparative advantage with a
demonstrated track record including in countries in fragile environments. It will also
promote effective utilization of PHC facilities and enable them to provide high-quality
services. Improvements in facility hygiene will make them safer. Power connections will
enable them to use a wide range of diagnostic and treatment technologies and offer more
continuous services. Digital connections will support health information flows and data
collection, for improved disease surveillance, and allow for digital solutions to be
implemented.
6.4 Offering mixed infrastructure investments in support of last-mile delivery will require deep
and effective collaboration across the Bank’s operational units. The team leading on the
SQHIA will need to develop strong collaborations – including potentially joint delivery
strategies and cross-functional teams – with the departments leading on energy, water and
sanitation, and digital connectivity.
6.5 The Bank will provide targeted support for health insurance and other social
protection schemes to help support access by the poorest and most marginalised to
health services. For these groups, financial barriers to accessing health services including
the costs of transport, drugs and user fees are hampering access and creating financial
hardship. The Bank will therefore work to promote the expansion of these schemes, with
an emphasis on ensuring the hardest to reach can utilise them.
6.6 The Bank will explore the potential for cost-effective innovation in PHC last-mile
delivery. There may be scope to package PHC with mini-pharmacies and small retail
spaces, for financial sustainability. PHC facilities could be supported by call centres and
virtual solutions, to access specialist expertise. The Bank will also explore options to
support mobile health services as well as the use of drone technology to supply PHCs with
blood supplies and other health inputs. The private sector is viewed as an important partner
to achieve this.

14
Pillar 2: Secondary and tertiary healthcare facilities
6.7 The Bank will utilise its extensive and niche experience in convening financing partners
to bring together private and public actors together to develop and finance innovative
secondary and tertiary healthcare infrastructure and catalyse replications across
Africa. Potential investments under this pillar include:
i) Cross-country hospital franchises: Financing the construction or expansion of high-
volume, low-cost secondary and tertiary private health service delivery infrastructure
franchises that leverage economies of scale and manage the growing NCD burden.
ii) Highly efficient mono-specialty hospitals: Co-financing the building of high volume,
low-cost mono-specialty hospitals focused on a single health challenge such as
maternity or cardiovascular disease. The Bank’s support would include TA to develop
viable projects and financing models, including PPPs, and identify private-sector
partners.
iii) State-of-the-art reference hospitals: Co-financing the establishment of regional
multi-specialty research and teaching hospitals that provide high-quality of care,
support clinical trials, and healthcare worker training. The Bank will help RMCs access
global expertise in the development of high-end health facilities, and advocate for
supporting policies (e.g., regional-level patient referrals, regional harmonization of
qualifications to facilitate mobility of skilled personnel).
iv) Multi-specialty secondary and tertiary hospitals: Financing the construction of
multi-specialty secondary and tertiary public health and supporting infrastructure,
focused on providing high-quality treatment to manage rising NCD burdens.
6.8 Investment in secondary and tertiary healthcare facilities will benefit all Africans, and
not just urban or middle-class communities. Poor and remote communities also need
access to hospital care and specialised services, which must be made affordable through
health insurance. Furthermore, the development of specialised health services benefits the
whole community, through in and out-patient support and potentially tele-medicine. It also
makes African countries better placed to respond to public health threats – including
COVID-19 – that require specialist or intensive-care support.
6.9 The Bank will deploy a wide range of financing instruments under this pillar.
Alongside traditional investment projects, it may offer result-based financing to support
enhanced policy dialogue and accompany government reform. Private-sector operations,
including debt and equity investments and risk-sharing instruments, may be used to support
PPPs, alongside TA to support viable PPP frameworks and models, and use of the Bank’s
convening power to support matchmaking with potential investors. Knowledge products
and TA will also be important to optimize the location and design of investments.
Pillar 3: Diagnostic infrastructure
6.10The Bank will provide finance to governments to set up and/or upgrade diagnostic
infrastructure. This support will help close financing gaps in expanding diagnostic
capacity to ensure that more of Africa’s population access diagnostic services and improve
the accuracy of diagnostic work across RMCs, for improved treatment and disease
surveillance. Currently, only 15% of the African population have access to diagnostic
services and up to 50% of essential diagnostics are inaccurate. To meet the projected
demand in 2030, the availability of diagnostic equipment and facilities such as MRI must
increase by over 100%. During COVID-19, weaknesses in diagnostic infrastructure have
emerged as a key constraint in the ability of national health systems to monitor and respond
to epidemic disease.

15
6.11 Sample initiatives will include under Pillar 3 will include:
i) High-volume outpatient diagnostics. Financing the expansion of high-volume
outpatient diagnostics by partnering with the existing Africa Health Diagnostics
Platform.
ii) Equipment upgrade. The Bank will provide financing to governments to upgrade
diagnostic equipment.
6.12 Diagnostics is an area that lends itself to private-sector involvement. This may include
basic outsourcing models or more complex PPPs. The Bank may provide a combination of
sovereign and non-sovereign financing together with technical support for PPP
development and matchmaking services. TA for regional alignment of standards will
potentially allow private investors to achieve economies of scale.
Cross-cutting thematic areas
6.13 Across all three pillars, the Bank will provide ICT connectivity that supports
improved health information systems and innovative approaches to health service
delivery. ICT connections have a key role to play in promoting access to quality health
services. They are a foundation for robust health information systems, which give policy
makers the means to monitor public health and the performance of national health systems
and identify bottlenecks in the provision of quality health services.
6.14 Leveraging ICT will also be key to expanding last-mile access to health services.
Investment in national or subnational digital health platforms could expand access to
outpatient care while reducing the need for new brick-and-mortar facilities. As well as
providing connectivity for new and existing health facilities, the Bank may also undertake
non-sovereign investments in companies offering innovations in health service delivery.
6.15 Potential investments could include:
i) A virtual outpatient platform – The Bank will identify partners to co-
finance/franchise a “virtual-first, in-person only when necessary” ecosystem for
outpatient (primary and specialist) care to help re-design outpatient care on the
continent. The platform would provide an end-to-end patient experience supported with
digital technology and portable devices, complemented by a reference network of
general practitioners, secondary and tertiary hospitals, and community health-worker
networks.
ii) Support to virtual outpatient platforms. These might include platforms established
by health professionals in the diaspora, as well as in-country.
6.16 A second cross-cutting theme will be promoting regional integration and collaboration.
A key element in meeting Africa’s need for quality health services is facilitating the regional
movement of skilled health personnel and creating larger and more efficient regional health
markets. The Bank will promote regional harmonisation on health policy and regulation in areas
such as health worker qualifications, treatment protocols and licensing of health technologies.
This will support the sharing of health technologies across the region, promote cross-border
healthcare investments and increase the availability of specialist health workers. Increased
regional collaboration will also make Africa more robust in the face of shared health threats
such as pandemics. It will help to increase access to specialised health services that are not
always available at the national level – particularly when combined with investments in digital
health platforms. Harmonisation of standards will also make health equipment more cost-
effective.
6.17 In order to promote regional collaboration on health, including during emergencies, the Bank
will leverage its role as convener and knowledge broker to deepen its partnerships with Africa

16
 CDC, WHO and UN agencies and continue to engage with all key partners within the platform
of the Harmonization for Health in Africa Programme.
6.18 Third, the Bank will ensure that all its health infrastructure investments are
accompanied by policy dialogue, technical assistance and capacity building. This will
enhance the prospects of strategic impact while minimizing the risks of ‘white elephant’
infrastructure projects that are poorly utilized due to shortages of finance or personnel. The
selectivity criteria in this strategy stipulate that the Bank will only invest in health infrastructure
that is anchored in credible national health system strengthening plans and financing
frameworks. This clear precondition creates a platform for the Bank to engage RMCs in policy
dialogue on health system strengthening in advance of project approval, starting at Country
Strategy Paper (CSP) and project identification stage. The Bank will also package its
investments where appropriate with complementary TA support. This may take the form of
including health finance-related measures in PBOs or using results-based finance that combine
investment finance with platforms for policy dialogue.
6.19 The Bank’s policy dialogue and TA will be tightly focused on ensuring effective
utilisation and sustainability of health infrastructure investments. The Bank will
support RMCs to put in place the policy and institutional frameworks needed to secure
sustainable financing, including health insurance, provide effective oversight of the health
sector, set standards for PPPs, and ensure that infrastructure investments result in
sustainable improvements in quality health services. Health finance will be a strong focus.
The Bank will support RMCs to develop strategies for financing their national health
systems, helping to make the case for prioritizing health within national plans. It will
support the development of plans and implementation strategies to expand national social
protection and health insurance schemes and improve their targeting of poor and
marginalized groups. It may include creating an enabling policy environment for private
sector investment, including outsourcing of specialized services (e.g., diagnostics, cold
chain management, and medical waste disposal) and the development of PPPs for service
delivery, as appropriate to each national context. With regards to PPPs, we will support
RMCs in developing PPP laws, policies and regulations, establishing PPP institutions, and
strengthening public sector capacity to identify, develop and implement PPPs in health.
6.20 Knowledge-based activities to support the health infrastructure portfolio will include:
i) Analytical work. The Bank will undertake a programme of targeted analytical sector
work, to assess emerging health challenges and infrastructure needs, explore innovative
service-delivery options and approaches to expanding service access to poor and
marginalized groups, and identify solutions to health financing challenges.
ii) Policy dialogue on health financing, broadening service access and related
challenges. The Bank will work with RMCs to develop and implement evidence-based
policy reforms to address critical challenges such as sustainable health service
financing, improving the effectiveness of health spending, and ensuring that poor and
marginalized groups are reached, in accordance with the ‘leave no one behind’
principle. In particular, the Bank expects to engage with RMCs on social protection and
health insurance schemes, to ensure that the poorest benefit from expansions in health
services. This will also promote better utilization of health infrastructure supported by
the Bank, increasing value for money from these operations.
iii) Technical support for innovative financing solutions and project preparation. The
Bank will draw on its extensive experience in infrastructure financing to help RMCs
develop innovative methods for financing health infrastructure. This will include
developing policy frameworks for PPPs and providing technical support for PPP project
preparation. A related challenge is the harmonization of health standards at the

17
 continental or subregional level, to make it possible for private investors to supply
medical equipment and health services more cost-effectively across regional markets.
6.21 The Bank’s TA and knowledge work will draw on its partnerships and networks
(Annex 3). While the Bank offer expertise in some areas of health infrastructure
development and financing, there are also many other sources of technical support for
RMCs. The Bank will cultivate links with other partners and networks – such as
Harmonization for Health in Africa (HHA) and the Global Network for Health Financing
and Social Protection (P4H) to help RMCs identify the right sources of technical support
for their needs. The Bank will also develop funding and programme partnerships with other
financiers of health in Africa, including development finance institutions and private
foundations, such as the Bill and Melinda Gates Foundation, Mastercard Foundation, Aliko
Dangote Foundation and others.
7. IMPLEMENTATION OF THE STRATEGY
7.1 The implementation of the strategy plan is articulated around the achievement of
targeted output, outcomes and results indicators as defined by the Result
Management Framework (RMF). The RMF captures all activities from sectoral
interventions across the defined pillars. Within the “One Bank” approach, joint
accountability for the achievement of targets and results pertaining to departments
interventions will be defined. This Strategy serves as unifying platform that ensures
optimal synergies between the various departments for a maximum impact.
Guiding Principles
7.2 The Bank will also ensure that its health infrastructure operations are guided by the
following set of principles.
7.3 Selectivity: The Bank will apply strict selectivity criteria to its health infrastructure
investments. The Bank will provide support only where:
- i) Comparative advantage – Health infrastructure has been identified in the CSP as a
national priority that the Bank is well placed to support, alongside other development
partners, having regard to its established expertise in infrastructure development and
financing, as set out in section 3.
- ii) Financing gap – Health infrastructure deficits are clearly identified as a barrier to
expanding access to quality health services.
- iii) National ownership – The proposed investment is anchored in a credible national
health system strengthening strategy and financing framework, that provides the
necessary conditions for the investment to be fully utilised and to expand broad-based
access to quality health services.
7.4 These elements should be identified in the first instance through Country Diagnostic Notes
and CSP discussions, and health infrastructure must be included as a priority in the CSP
prior to any offer of public sector support. Where national strategies need strengthening,
the Bank may opt to provide technical support and policy dialogue to support their further
development, before committing to the investment. Working in this way will help to ensure
there is full ownership of health infrastructure interventions by public and private sector
stakeholders, which will in turn help to secure local financing for the operation and
maintenance of the infrastructure, to promote resilience and sustainability.
7.5 Flexibility and customization: The implementation will embed enough flexibility to
accommodate a tailored support for each RMC, reflecting their diverse health needs. The
Bank’s support will be locally driven, responsive to the specific health challenges each

18
 country faces. It will invest in diagnostic studies, where appropriate, and ensure flexibility
in adapting to diverse national contexts.
7.6 Partnerships: The Bank will continue to strengthen its partnership and alliances with all
key stakeholders involved in the health systems development. It will strive to be a catalyst
of the design and application of innovative solutions to address the most challenging
situations faced by RMCs, particularly Transition States through a clear division of labour
with other partners.
7.7 Inclusivity: Bank’s interventions will aim to create conditions that promote equitable
health solutions and access for the poorest communities and households. In accordance
with the ‘leaving no one behind’ principle, the Bank will work with RMCs to ensure that
health services are available to low-income and marginalised groups on an equitable basis.
In particular, through its policy dialogue and technical assistance, the Bank will ensure that
country policies and budgetary allocations are in place to improve access to health facilities,
including secondary and tertiary health facilities, to poor people at affordable cost. The
Bank will also ensure that its interventions respond to the diverse needs of women and girls,
the elderly and people living with disabilities.
7.8 Sustainability: The Bank will leverage its extensive experience of combining infrastructure
financing with complementary support to promote the sustainability of investments. Through
policy dialogue, technical assistance and knowledge products and anchored in the National
Health Systems Strengthening plans of RMCs, the Bank will promote prudent and effective
investment financing for accessible, well utilized and inclusive quality health infrastructure that
involves greater participation of private sector, promotes green and climate resilient facilities
and leverages technology and innovation.
Implementation Plan
7.9 The Bank already has a pipeline of projects to fund and will immediately but gradually
begin to increase its investments in health infrastructure. The Bank has been receiving
proposals for new health infrastructure projects, stimulated by its increased emphasis on
this area in recent years. An initial modest scale-up in our financing will be delivered by
supporting these projects and be overseen mainly by health experts who have successfully
delivered the Bank’s response to COVID-19 pandemic. It is also likely that in the early
years of implementing this strategy, further demand will only increase gradually, given that
- the prioritization of health infrastructure in RMCs will depend on the preparation of new
CSPs in the pipeline.
7.10To support this gradual scale up in investment and the delivery of this strategy, the
Bank has developed an action plan. This action plan (see Annex 2) specifies actions to
be carried out across the lifetime of this strategy to deliver each pillar and the
complementary priorities in knowledge work, policy dialogue and technical assistance. It
also identifies the lead and partner departments responsible for undertaking these actions
in the spirit of delivering as ‘One Bank’.
7.11A key element of the action plan are the actions we will undertake to lay the
foundation for and to begin implementing this strategy. These actions are presented
below and are also detailed in section 6 – ‘Supporting internal processes’ - of the action
plan in Annex 2):
i) Progressive development of in-house capacity. The Bank has sufficient capacity to
manage the scaling up of its health infrastructure portfolio anticipated in the coming
years. This capacity revolves around existing health experts - that have successfully
managed the responses to COVID-19 pandemic and recent Ebola outbreaks. The health
team will work in close collaboration with other infrastructure investment and

19
 ecosystem experts under the ‘One Bank’ delivery model. The existing country team
framework will provide a reliable cross departmental platform for planning and
implementing the SQHIA work program within the context of the CSP. The annual
Work Program Agreements with the regions will help secure commitment to deliver as
‘One Bank’ with the new co-efficient budgeting and joint Key Performance Indicators
promoting shared accountability. In-house expertise on health infrastructure will be
gradually consolidated as part of the Bank’s ‘right sizing’ exercise, as human resources
are matched to emerging priorities. An assessment will be carried out as part of the mid-
term evaluation to determine whether additional human resources are required to
manage the portfolio from that point.
ii) Strengthen networks and coordination within the Bank. The Bank will take a ‘One
Bank’ approach to delivering the SQHIA, to ensure that all the Bank’s expertise is available
to support RMCs. It will identify sources of expertise in different aspects of infrastructure
development and project finance across departments and within existing project preparation
facilities. It will convene cross-departmental teams and establish a regular cadence for joint
working and collaboration on project origination and design. NSO staff with the experience
needed to process quality health infrastructure projects will be made available to support
implementation of the strategy.
iii) Cultivating external networks and partnerships. The Bank will follow a partnership
model to delivering the SQHIA. The Bank’s health infrastructure portfolio is a niche within
the larger health ecosystem that requires the cultivation of strong relationships and
networks. The SQHIA delivery team will build its links to key development partners,
including Africa CDC, UNICEF and WHO, the World Bank, Development Finance
Institutions (such as the IFC and CDC) and private foundations (such as the Bill and
Melinda Gates Foundation), in order to facilitate the exchange of technical and country-
specific knowledge. This may include undertaking joint analytical work. Partnerships will
also be sought to ensure support in identifying private investors and supporting project
development. During project appraisal and design, the Bank will consult closely with
development partners active in-country, utilizing existing forums such as health sector
HHA for Health in Africa and the P4H network. The World Bank will be a key partner to
engage in securing effective division of labour in supporting primary healthcare
facilities, and in designing climate friendly healthcare investments.
iv) Designing a structured programme of knowledge work. During the early phase of
strategy implementation, the Bank will design a structured programme of analytical
work, based on the available data on Africa’s evolving health needs and service gaps,
to inform identified priorities for evidence collection. It will synthesize the available
knowledge and evidence on effective strategies for filling health service gaps, across
different African country contexts, and collect lessons and experience. It will develop a
programme of analytical work to fill the identified knowledge and evidence gaps. This work
will build on the scoping analysis already undertaken to inform this strategy, assessing
evolving needs as a result of the COVID-19 pandemic and provide a foundation for the
Bank’s policy dialogue and TA.
v) Identifying technical assistance providers. To strengthen its capacity to provide TA,
building on its existing networks, the Bank will develop partnerships with institutions
offering technical expertise in key areas and develop a range of options to meet the technical
needs of RMCs.
vi) Strategy dissemination. The implementation team will identify opportunities through
existing events and processes to present the strategy and the Bank’s health infrastructure
offer to African governments, regional economic communities, other development
partners, health service delivery companies, financial institutions, and other
stakeholders. To support the communications plan, the team will conduct a mapping of

20
 stakeholders. The focus of communication will be on promoting awareness of the
opportunities provided by this strategy while being very clear about the Bank’s focus
and selectivity criteria.
7.12 Financing instruments. The Bank will use a range of financing tools to support RMCs with
health infrastructure development, as follows.
i) Traditional investment projects, with the focus on larger projects, with flexibility
retained to support ADF countries with last-mile delivery in primary health care.
ii) Results-based financing, which combines investment projects with programme-based
operations (PBOs), for enhanced policy dialogue on health system financing
challenges, including social protection and health insurance.
iii) Public-private partnerships (PPPs), combining technical support for the
development of PPP frameworks and models, together with risk-sharing instruments to
help mobilize private investment.
iv) Non-sovereign operations, including debt and equity investments in private firms,
with a particular focus on firms able to offer regional investments in health services
and medical equipment. The Bank’s technical assistance will include support on
regional harmonization of health standards, to help viable health businesses achieve
efficiency through scale.
v) Innovative finance options, including diaspora investment funds. This could
include a dedicated funding mechanism to provide Viability Gap Funding for a portion
of the capital costs of health infrastructure projects, or the issue of a diaspora bond for
health infrastructure, to attract diaspora savings. This would be accompanied by policy
dialogue and TA to RMCs on policy measures and initiatives to attract diaspora
funding.
7.13 The SQHIA will be accompanied by a robust monitoring plan. A monitoring framework
for the strategy is attached in Annex 1, and extensive work will be undertaken to monitor
delivery through data collection from projects and through close engagement with national
institutions in order to track the status on health service delivery infrastructure. An annual
report will be prepared on implementation of the strategy, including feedback from RMC
counterparts. This will cover pipeline development, knowledge work, approvals, and output
indicators. A mid-term review in 2026 will assess emerging results to inform a review of the
strategy.
Figure 4: Linkages to other Bank strategies

Other relevant strategies Potential synergies with SQHIA

▪ Strengthening Africa’s capacity to prevent and treat medical
Pharmaceutical Action Plan*
conditions in a cost-effective and timely manner
▪ Overcoming gender disparities in access to health (e.g., finance,
Gender Strategy*
technology, quality of care)
Feed Africa Strategy ▪ Improving nutritional health and grey matter infrastructure

▪ Support the development of resilient and efficient health service

Fragility Strategy delivery infrastructure in situations of fragility and conflict-
affected areas
▪ Developing health service delivery infrastructure projects which
Governance Strategy find the right balance between economy, efficiency and
effectiveness
▪ Champion climate-resilient and low-carbon health service
Climate change action plan delivery infrastructure development in order to mitigate and
adapt to climate change
WASH strategy ▪ Integrating health KPIs in WASH projects

21
 ▪ Increasing connectivity of health service delivery infrastructures
to WASH utilities
▪ Integrating health KPIs in infrastructure projects
Infrastructure strategies (e.g., ▪ Increasing connectivity of health service delivery infrastructures
energy, IT, urbanisation) to utilities
▪ Investing in off-grid solutions to connect PHCs to power
▪ Strengthening of PPPs for health service delivery infrastructure
Designing the AfDB’s PPP
development
framework
▪ Leveraging knowledge on project preparation set-up
▪ Driving demand of private sector players to develop
Private Sector Development
partnerships with national governments (i.e., for PPPs)
Skills for Employability and ▪ Investing in training infrastructure for health personnel
Productivity Action Plan
▪ Support health serviced delivery infrastructure development
Industrialization Strategy with necessary manufacturing implicated within the value chain
(e.g., equipment)
▪ Develop capabilities of national authorities to manage health
Capacity development strategy
service delivery infrastructure projects funded by the Bank
▪ Developing cross-border policies and frameworks to develop
Strategic Framework for virtual outpatient platforms; set-up regional COEs and
Regional Integration diagnostic centres, establish medical referrals; elaborate data
sharing protocols; align on health workforce qualifications
▪ Support access and training of youth to medical value chain
Jobs for Youth in Africa
workforce to address gap in both employment and staffing of
Strategy
these resources
▪ Support knowledge generation on the challenges and
Knowledge Management
opportunities of financing of health service delivery
Strategy*
infrastructure
* Under development or pending approval

8. RISKS AND MITIGATION

8.1 This strategy aims to deliver high impact results for the people of Africa and improve their
welfare on a sustainable basis and for the long term. Seven major risks have been identified
which require monitoring and mitigation as set out below.
Figure 5: Risk and Mitigation Measures

Risk Mitigations
Slow economic recovery after the ▪ Bank financial support to facilitate investments in health infrastructure
pandemic and rising indebtedness ▪ Bank technical assistance on health system financing options
result in RMCs lacking the resources to ▪ Innovate financing solution to help mobilise private investment in
invest in health system development health care including from the African diaspora
Lack of political support for ▪ Credible national health system strengthening plans and financing
investment in health system arrangements set as preconditions for Bank support
strengthening, resulting in a lack of ▪ Use the CSP dialogue and ongoing high-level political dialogue to
credible policies and strategies, and leverage increased budget commitments and strengthen mobilisation
low prioritisation of health in of co-financing from DFIs, bilateral donors, private foundations and
government budgets and a failure to fill others
the $26 billion financing gap on health ▪ Invest in knowledge work, to support policy dialogue and encourage
infrastructure. policy change (in particular, leverage existing work on value for
money , financing gaps, innovative financing mechanisms and public-
private collaboration in health)
▪ Provide technical advisory services to RMCs to strengthen revenue
mobilisation and health spending prioritisation, and showcase
innovations in health services
▪ Deploy relevant Bank instruments and platforms (e.g ALSF, AIF) to
support RMCs in mobilising private capital for health infrastructure
Limited buy-in from other ▪ Consultation at strategy design stage
development partners, resulting in ▪ Active communication around the Bank’s health offer

22
 limited opportunities for harmonised ▪ Proactive exploration of co-financing opportunities in CSPs and at all
approaches and co-financing stages of project cycle
▪ Mentor RMCs for enhanced coordination and collaboration
Insufficient buy-in from private ▪ Support regulatory developments at country and regional level to
sector due to a perception of high catalyse and facilitate investment
investment risk, resulting in low ▪ Invest in model projects to demonstrate results, and communicate on
appetite to invest and hampering results
innovation ▪ Develop innovative PPP models
▪ Promote innovative instruments and risk-sharing, to facilitate viability
gap financing
Lack of regional ownership and ▪ Increase coordination with the support of the AU, national
capacity result in non-prioritisation of governments and RECs, also using partnerships with HHA, P4H and
health regulation harmonization Africa-CDC
initiatives ▪ Build on Bank collaboration with RECs in responding to the COVID
pandemic, and use lessons learned from the Regional Integration
strategy
▪ Strengthen capacities of RMCs and RECs on harmonisation of health
regulations
Lack of internal ownership of the ▪ Observe strategy selectivity and the Bank’s selectivity guidelines
health portfolio within the Bank, ▪ Document, report and disseminate results from health infrastructure
resulted in underinvestment and a lack projects
of synergy with other portfolios ▪ Develop working arrangement for strategy implementation in
accordance with the One-Bank approach
▪ Develop shared KPIs and accountability processes

9. CONCLUSION
9.1 The SQHIA provides a clear strategic framework for better Bank engagement in the field
of health infrastructure. It follows high demand from RMCs for the Bank’s support, made
more urgent by the COVID-19 pandemic and confirmed by extensive external
consultations. While recent investments have been made without a clear strategy, SQHIA
is a tightly focused strategy based firmly on the Bank’s comparative advantage, with clear
selectivity criteria for identifying which projects to support. In this way, the strategy
ensures that the Bank’s support on health infrastructure remains within its areas of
expertise. To ensure that the Bank’s infrastructure investments lead to sustainable
improvements in health services, the strategy provides that investments must be anchored
in credible national health system strengthening plans and financing frameworks, working
alongside other development partners. The Bank will make use of its full range of financing
instruments, including NSOs, to encourage private investment in health infrastructure. All
investments will be accompanied by policy dialogue and technical assistance, focused on
health financing, health insurance, PPP development, and regional integration, to help
promote an enabling environment for effective use of infrastructure and promote equitable
access to quality healthcare.

23
Annex 1: SQHIA Results Framework

Monitoring and evaluation

To measure the impact of the healthcare infrastructure projects, the strategy will make use of
existing Bank systems and will promote increased monitoring at the Bank-wide, department, and
project-specific level. While M&E for this strategy will be led by the health team, effective
collaboration is required across key Bank departments for success. The M&E cycle includes data-
collection mechanisms for primary and secondary sources. The process is supported by a detailed
results-measurement framework (RMF) which will only monitor critical success elements in the
Theory of Change that underpin the achievement of the final outcomes. The framework details
metrics and targets at three levels; impact, outcome and outputs designed to assess the contribution
of the Bank to the results. In addition, a mid-term review is planned to be undertaken in 2025, to
assess the implementation of the strategy and inform any changes that may be necessary.

All SQHIA health projects will strictly follow new best practice standards with regards to project
results frameworks, monitoring plans and theory of change; as well as consistent use of mandatory
monitoring reports and robust PCRs and XSRs, which will greatly enable aggregation of project
results at strategy level. In-depth training on effective application of these tools is planned for
existing and new health sector staff. Secondary sources will include data bases like the UN SDG
database, World Development Indicators (WDI) and the WHO Global Health Observatory. Primary
data sources will include AfDB analytical studies and AfDB project reports. For indicators that
measure results in AfDB-supported countries, the baselines and targets in the RMF use continental
figure which will be revised through analytical work in the relevant countries as the pipeline of
operations is developed and will be updated as required over the life of the strategy. The 2022
indicative pipeline of analytical work includes analysis of selected health financing strategies in
RMCs. The analysis of CSPs and Health System Strengthening Strategies/Plans will initially be
for countries that have already expressed interest for health infrastructure lending. Then this will
subsequently be a norm for all countries that express interest.

In order to strengthen its internal capacity to implement its M&E framework, AHHD will closely
collaborate with ECST to source relevant statistics, and SNOQ2 and BDEV3 to enhance a
successful implementation of the M&E system.

Results framework

Results chain TARGET AT FREQUENCY

UNIT OF BASELINE MEANS OF
and indicator MEASUREMENT (date)
COMPLETION
VERIFICATION
OF DATA
description (2030) COLLECTION

❚ IMPACT STATEMENT: Increased access to quality health services for the people of Africa
by 2030
SDG 3.8.1
Universal Health UN SDG data;
% 48.9 (2015) 100 Every 5 years
Coverage index of WDI
service coverage
SDG 3.8.2
Proportion of
population with
No WHO Global
>10% of household
% 71.06 (2015) internationally Health Every 5 years
expenditure on
agreed target Observatory
health as a share of
total household
expenditure

I
 ❚ OUTCOME STATEMENT 1: Increased availability of quality health services
1.1 Share of WHO UHC
population with Global
access to essential % in AfDB- Monitoring
70 80 Every 2 years
health services supported countries Report/The
within two hours Global Health
from home3 Observatory
WHO UHC
Global
# beds per 1,000
1.2 Hospital bed Monitoring
people in AfDB- 1.2 2.0 Every 2 years
capacity Report/The
supported countries
Global Health
Observatory
❚ OUTCOME STATEMENT 2: More effective and resilient national health systems
% of
2.1 Increased coverage of national population in AfDB
Every 2
health insurance amongst poor and AfDB- 0 10 analytical
years
marginalised populations supported study
countries
WHO Global
2.2 Out-of-pocket expenditure as % Every 2
% 38 35 Health
of recurrent health expenditure years
Laboratory
$ value of
private sector
2.3 Private investment mobilised into AfDB project Every 2
contributions 0 TBD *
health reports years
to AfDB-
support PPPs
❚ OUTPUT STATEMENT 1: Health infrastructure supported by AfDB
1.1 Countries (LICs/FSs) supported AfDB project
# countries 0 20 Annual
with PHC infrastructure reports
1.2 Diagnostic infrastructure # diagnostic AfDB project
0 10 Annual
supported facilities reports
AfDB project
1.3 Hospital beds delivered # beds 0 23,000 Annual
reports
❚ OUTPUT STATEMENT 2: Cross-cutting themes
1.1 Number of health facilities
Number 0 15 AfDB reports Annual
provided with ICT connections
1.2 Number of countries supported to Number 0 5 AfDB reports Annual
align with regional health standards
1.3 Number of health-related
Number 0 15 AfDB reports Annual
knowledge products published
1.4 Number of countries supported to
strengthen health system
strengthening plans, financing Number 0 10 AfDB reports Annual
framework or develop PPP
frameworks and models

* For indicators that measure results in AfDB-supported countries, the baselines and targets
will be calculated through analytical work in the relevant countries as the pipeline of
operations is developed and will be updated as required over the life of the strategy.

3
Low coverage Archetype A countries

II
Annex 2: SQHIA Action Plan

Deliverables Actions Lead Time

department & -frame
partner
departments
Pillar 1: Primary Health Care Infrastructure
1.1 Finance primary healthcare • Identification of projects; pipeline development AHHD RDVP 2022-2030
infrastructure expansion, • Verification of health sector strategic plans and financing departments,
particularly in fragile states and plans, engagement with health sector development partner PEVP, AHWS,
some LICs, to reduce the last-mile fora. PITD.3 PICU,
access gap. • Support both new and existing health facilities to connect to RDTS, SNSC,
water and sanitation services, electricity connections, and AHGC, SNFI
digital services.

1.2 Support cost-effective innovation in • Support PHC facilities with call centres and virtual solutions, AHHD, PICU, 2023-2030
PHC last-mile delivery, to facilitate to access specialist expertise. PITD.3, RDVP
equitable access •Support mobile health services as well as the use of drone departments
technology to supply PHCs with blood supplies and other
health inputs.
Pillar 2: Secondary and Tertiary Healthcare Facilities
2 Development of secondary and • Financing the construction or expansion of high-volume, low- AHHD, PINS, 2023-2030
tertiary health care facilities, cost secondary and tertiary private health service delivery PICU, SNSC,
alongside specialist facilities for infrastructure franchises. RDVP
cancer, dialysis, and pain • Co-financing the building of high volume, low-cost mono- departments,
management. specialty hospitals focused on a single health challenge such AHGC, SNFI
as maternity or cardiovascular disease.
• Co-financing the establishment of regional multi-specialty
research and teaching hospitals that provide high-quality of
care, support clinical trials, and healthcare worker training.
• Financing the construction of multi-specialty secondary and
tertiary public health and supporting infrastructure, focused
on providing high-quality treatment to manage rising NCD
burdens.

III
 • Business development to identify private sector partners and
investors at country level.
• Development of instruments to enhance private sector
participation.
• Development of Advisory services and TA for private sector
investors
Pillar 3: Diagnostic Infrastructure
Greater availability and utilisation • Financing the expansion of high-volume outpatient AHHD, PINS, 2023-2030
3
diagnostics by partnering with the existing Africa Health PICU, RDVP
of diagnostics.
Diagnostics Platform. departments,
• Provide financing to governments to upgrade diagnostic SNSC, AHGC,
equipment. SNFI
• Provision of a combination of sovereign and non-sovereign
financing together with technical support for PPP
development and matchmaking services.
Connectivity for Innovative Health Services
4 Increasing uptake of innovative • Support the provision of ICT infrastructure to enable RMCs AHHD, PICU, 2024-2030
health solutions. to introduce innovative approaches to health service delivery. PITD.3, SNSC,
SNFI, RDVP
departments
Knowledge work, policy dialogue and technical assistance
5.1 Knowledge work - Support the • Preparation of sector diagnostic notes AHHD, ECVP, 2022-2030
generation of knowledge products • Knowledge work on Public-Private Collaboration in health, SNSP
to facilitate evidence-based policy to explore successful and equitable approaches
making on health infrastructure • Knowledge work on health insurance approaches tailored to
poor and marginalized groups
• Knowledge work on Value for Money in health and related
evidenced based policy dialogue and technical assistance.
5.2 Policy dialogue - Undertake high • Facilitate dialogue through the CSP mission to explore health AHHD, ECGF, 2022-2030
level policy dialogue to promote challenges and identify relevant priorities RDVP
effective resourcing, utilisation and • Policy dialogue to support the development of comprehensive departments,
functioning of health infrastructure health financing strategies, including measures to expand SNSP
public finance, to leverage private sector investment and to
collaborate with other actors

IV
 • Policy dialogue to support the development and
implementation of social protection schemes, with a
particular emphasis on poor and marginalized groups
• Policy dialogue to provide regional responses to health
challenges, including on health worker regulations, treatment
protocols and licensing health technologies
5.3 Technical assistance (TA) – • Support technical assistance to assist the strengthening of AHHD, ECAD, 2022-2030
Support demand-led and tailored national health system and health financing strategies PICU
TA to build capacity of local • Support technical assistance to assist the development and
institutions to manage an effective implementation of social protection schemes, with a
and equitable health sector particular emphasis on poor and marginalized groups
• Support technical assistance to assist the exploration, design
and implementation of effective and equitable PPP projects
Supporting Internal Processes
6.1 Progressive development of in- • Set up the health-service delivery infrastructure strategy AHVP front 2022-2023
house capacity implementation team, by assigning roles, identifying any office, SQHIA
additional skills required, applying an established governance Coordination
system to implement the strategy, and setting up a working Taskforce
cadence with other divisions. Members, PICU
• The team will leverage infrastructure, PPP and investment PPP Unit,
experts to deliver the strategy. African Legal
Support Facility
(ALSF)
6.2 Enhancing networks and • Ensuring cooperation with other AfDB departments, and AHVP front 2022-2030
coordination within the Bank relevant internal strategies, to ensure that the health-service office
delivery infrastructure strategy’s cross-cutting objectives are
met.
6.3 Cultivating effective external • Use of the Bank’s unique convening power to mobilize a wide AHHD 2022-2030
networks and partnerships. range of stakeholders. These include private-sector players
such as international and local health-service providers,
health start-ups, faith-based organizations, and universities
and research centers; co-financiers such as DFIs, commercial
banks, and investment funds; public institutions such as
government bodies and NGOs; and multilateral institutions
such as the WHO or UNIDO.

V
6.4 Designing a structured programme • Mapping and scoping of existing data sources and knowledge AHHD, ECVP 2022-2030
of knowledge work resources around health sector strengthening and financing,
PPPs and other issues
• Design of a structured programme of knowledge work
6.5 Identifying technical assistance • Scoping to identify organisations to partner with technical AHHD 2022-2030
providers assistance providers, and initiating the development of
partnerships with them
6.6 Strategy dissemination • Communicate and mobilize external stakeholders to raise AHHD, PESC 2022-2023
demand by championing the strategy internally through a
defined communication plan, presenting the strategy to
international and local stakeholders, identifying the possible
positioning of each player in the strategy, and defining
partnership opportunities.
Review and evaluation
7.1 Mid-term Evaluation of the strategy • Conduct a mid-term review of goals and results, AHHD, SNOQ, 2026
implementation • Adjust the strategy accordingly, BDEV
• Request approval for additional financing as appropriate,
• Scale-up of the strategy through steering investments into
successful projects.
7.2 End of strategy implementation • Conduct a full-term review of goals and results AHHD, SNOQ, 2030
• Adjust the strategy based on lessons learned and the existing BDEV
context.

VI
Annex 3:Strategic Approach to Partnerships in Support of Africa’s Health
Infrastructure

This annex presents an overview of the processes and approaches that will be used to ensure
that the Bank pursues a targeted agenda for developing strategic partnerships required to fulfil
the ambitions of the SQHIA.

A smart and disciplined strategic focus

Health infrastructure financing needs across Africa are enormous, with capital investment in
the sector currently running at $5-$6 billion and a $26 billion financing gap facing the
continent.
Given this financing gap, it is imperative that AfDB – as the continent’s premier infrastructure
DFI – play a more significant and catalytic role going forward. Whilst the huge financing needs
reduce the risks of duplication, it is vital that the Bank identifies areas in which it can best add
value to the efforts of its RMCs and other development partners so as to maximize the value
for money and impact of its support. Building on lessons learned and informed by the Scoping
Study outcomes, the Bank has therefore been working intensively to identify its niche roles in
supporting health infrastructure in Africa. These niches are presented below:

• Effective and broadly utilized primary healthcare infrastructure - While the

current primary health care infrastructure could, theoretically, address expected
demand, facilities lack accessibility particularly in fragile countries where, the Bank’s
deep government connections could be leveraged to advocate for fit for purpose
primary infrastructure. It also has extensive experience of providing mixed
infrastructure support – including for electricity, WASH and digital connectivity – to
primary care facilities.

• Greenfield and mono-specialty hospitals - There are significant gaps in greenfield

secondary and tertiary health care infrastructure, especially in innovative institutions
like mono-specialty hospitals; AfDB has an advantage of already having experience in
setting up such infrastructure and the ability to mobilize public viability gap funding to
de-risk such high capital investments.

• Diagnostic infrastructure - Diagnostic infrastructure has one of the largest gaps that
cannot be narrowed without the private sector and PPP mechanisms. AfDB can
leverage its strong government relationship and it’s new PPP framework to support
member states both in setting up the right PPP frameworks and mechanisms, as well as
to facilitate engagement between the public and private sector.

• Connectivity - There has traditionally been very limited investment in connectivity for
innovative healthcare solutions partially due to the need of private sector involvement
and the need for stakeholder facilitation that are strengths of AfDB. AfDB is well placed
to response to this need as a historical infrastructure Bank, with a unique understanding
on Africa as well as investor needs, a range of financing instruments and expertise,
relevant to infrastructure, significant convening power and being a trusted partner
among private and public stakeholders. AfDB can take an important role in bridging
the gap between the private innovators, governments and the DFIs by providing

VII
 catalytic concessional financing and even equity investment in pilot projects and proof
of concepts, therefore de-risking further investments.

Building effective strategic partnerships

Central to our approach to developing strategic partnerships will be the process for developing
and agreeing Country Strategy Papers (CSPs) with RMCs. The CSP will be a key instrument
for first level engagement with national stakeholders to identify any health infrastructure
priorities and develop the analytical, policy and strategic foundations of our health operations.

The Bank will use the CSP country diagnostic and dialogue mission to establish the existence
of a credible National Health Systems Strengthening Plan (NHSSP) and its financing
framework, assess Government ownership, and map national institutions and organisations
vital to the functioning of the health system. This will help the Bank to prioritise which of these
institutions and organisations it should emphasise in developing partnerships and to tailor its
engagement with each.

The CSP dialogue mission will also allow the Bank to map other development partners and
international actors active in the health sector, and to engage them in dialogue on how the Bank
can be best add value to their work within the constraints of its core strategic priorities on health
infrastructure. This will include understanding where the existing gap in support lies in the
context of the Bank’s niche, both in terms of the specific infrastructure areas it supports and
the types of finance and complimentary support (in terms of knowledge work, policy dialogue
and technical assistance) it provides. It will position its funding to play a catalytic role to
mobilise additional financing for infrastructure from other DFIs, bilateral donors, private
sector, private foundations, African diaspora and others.

Key elements of the dialogue and diagnostic work on financing in each RMC will relate to
increasing and more efficiently utilising budget allocations for health and exploring the
potential for direct private sector investment and public private partnerships (PPP) to add value.
Support on government budgets will be guided by political economy analysis, to identify the
partnership approaches with government which can strengthen its support and leadership.
Exploring opportunities for PPPs will involve understanding the distinct roles of the public and
private sectors, where PPPs can add most value and the role of Bank in facilitating them.

Once the Bank has identified its niche area of health infrastructure support in an RMC, it will
also look to identify and explore partnerships with the full range of advisory and expert
organisations active on these health infrastructure issues regionally and globally including
WHO Afro, Africa CDC, UNICEF, HHA partners, academia and others. This will help the
Bank to efficiently and effectively leverage in their ideas to the knowledge work, policy
dialogue and technical assistance the Bank will support. Partnerships harnessed during design
and implementation of COVID-19 response operations provides good lessons for the Bank.

VIII
Annex 4: Bank’s Support for COVID-19 Response in South Sudan

The African Development Bank, through a 3 million UA ($4.14 million) ADF grant, is
financing the “Emergency Assistance to Support the Covid-19 Response in the Republic of
South Sudan”. The World Health Organization (WHO) is implementing the project, executed
by South Sudan’s Ministry of Health.

Working with the Ministry and WHO, the project covers 3 broad components aiming to boost
South Sudan’s pandemic emergency preparedness:
-Supporting emergency response for COVID-19 prevention and case management
-Building health systems capacity for emergency preparedness
-Project management and coordination.

To date, Bank financing has supported the renovation or upgrade of four health facilities in the
cities of Yei, Nimule, Aweil, and Wau. Funding has also supported the procurement of 51
oxygen concentrators, 13 patient monitors, 122 pulse oximeters, 71 blood pressure machines
and 9,240 nasal cannulas that have been distributed to 17 facilities, along with essential
medicines, supplies for triage and enough personal protective equipment (PPE) to outfit an
estimated 3,900 health workers.

In addition, 406 health care workers – approximately 25% of them women - across the country
completed Covid-19 case management training. Surveillance and case management tools were
developed to facilitate reporting at facility levels. Eighty- health care workers in sentinel sites
received training and incentives to adopt and use the pandemic surveillance tools.

The Bank assistance helped establish ten sentinel sites outside of Juba to scale-up surveillance
capacities at sub-national level. Two vehicles to support Covid-19 surveillance activities were
procured. A second floor was built at an Emergency Operation Center to support coordination
activities. Project implementing and executing partners also report that additional laboratory

IX
supplies now available are supporting the ability for authorities to decentralization testing for
Covid-19 and other priority diseases.

The project has procured, an oxygen generation plant Juba teaching hospital – the first of its
kind in South Sudan. The plant has an oxygen generation capacity of 2,500 litres per day and
the abilty to refill approximately 72 D-type oxygen cylinders per day and will act as a
centralized production and supply hub for remote locations. The procurement includes 240
oxygen cylinders for use, as well as spare parts and repair service agreement for four years.

“The installation of
the oxygen
generation plant is
good news to our
population and
marked the
beginning of the
country’s
preparedness for
oxygen in
anticipation of the
third wave of Covid-
19. South Sudan will
no longer be
importing oxygen
from the
neighboring
countries, and this means oxygen will be supplied to the facilities on time and more lives will
be saved,” said Honourable Elizabeth Acuei, South Sudan’s Minister of Health. The Minister
said that South Sudan authorities earmarked budget for the oxygen plant’s sustained operation
and maintenance. African Development Bank Country Manager for South Sudan, Benedict
Kanu, said that providing the oxygen plant is part of joint efforts to build a robust and well-
functioning health system in South Sudan.

“The Covid-19 pandemic remains a major threat to South Sudan’s population and elsewhere in
Africa. The Bank will continue to work with the government of South Sudan and its
development partners like the WHO to ensure a timely response to the pandemic and future
public health emergencies to save lives and livelihoods,” Kanu said.

X
Annex 5: Methodology for Assessing Health Infrastructure Deficits
The methodology applied to estimate demand for health services in 2030 is based on (a) country
archetypes defined by epidemiologic and demographic trends that drive demand for care 4 and (b)
infrastructure population density of benchmark countries that have gone through similar disease
burden trajectories to serve as proxies for each country archetype. The methodology to estimate
supply is based on the current existing supply of healthcare infrastructure, projected forward to
2030, assuming that the current infrastructure density will apply to the growing population. The
exhibit below provides further detail on each of the steps taken to estimate infrastructure demand
and supply, and the resulting expected gap by 2030.

Obtaining data across the countries was a challenge and adaptations were made to get the most
robust answers possible. The largest data gaps were in current existing healthcare infrastructure
across countries. Despite these data limitations and adjustments, the resulting estimates are
directionally found to be aligned with other leading organizations’ publications, including
UNECA’s findings and WHO’s benchmark.58

This analysis was carried out during the ongoing COVID-19 pandemic. While the pandemic has
had and will continue to have wide-reaching effects on disease burden, there is not yet published
data on country-level disease burden that considers the shocks from COVID-19. We do however
recognize that COVID-19 will likely impact the health infrastructure needs going forward and has
highlighted the need for developing more resilient and adaptable infrastructure.

The translation of the infrastructure gaps in terms of quantity (e.g., number of beds) into capital
expenditures (capex) is based on unit costs. The assumption for capex per bed was determined
based on benchmark data in Africa, where data was available (Algeria, Tunisia, Morocco, Kenya
and South Africa), as well as countries with comparable economies. Even within the same

4
Data on disease burden and epidemiologic evolution is from Fitch solutions

XI
country, capex per bed would be highly variable, driven by market dynamics such as the amount
of imported equipment and devices used, the manufacturer, and the type of facility (public or
private). Therefore, more accurate capex estimates would only be possible at the project level,
when assessing specific infrastructure projects as the Bank implements the strategy.

XII
Annex 6 : Analysis of Financial Flows into Africa’s Health Infrastructure
Methodology
As part of the scoping study to develop this strategy, an effort was made to estimate the historic
financing flows into Africa’s health infrastructure. The primary data source used is the CRS
(creditor reporting system) Aid Activity database from OECD. This database aggregates data on
official development assistance (ODA), other official flows and private development finance flows
towards basic health infrastructure (district-level hospitals, clinics, dispensaries and medical
equipment) and medical services (laboratories, specialized clinics and hospitals, ambulances,
dental services, and medical rehabilitation). Data is likely not exhaustive of each institution’s total
financing for health infrastructure, depending on the nature of the financing and how it is reported.
Other sources of data used include WHO, IFC and World Bank to estimate the annual investments
for health service delivery infrastructure in Africa, and the split between public and private
financing. There were data limitations on financing flows for health infrastructure into the
continent, with a need to triangulate estimations from multiple sources. There is need to improve
data and tracking of financing flows as a public health good and to enable this strategy.
Findings
African governments’ capital expenditure in health is at a low level compared to other regions
and showing signs of a gradual decline. Overall, financing for health infrastructure in Africa has
been low, at approximately $5 billion to $6 billion in annual Capex investment. The bulk (>80%)
of this has been in public sector infrastructure, developed by governments and financed mainly
through borrowing. While there is no WHO target, many countries in Asia and Latin America (e.g.,
Laos, Vietnam, India or Bolivia) spend more than 20 percent of government health expenditure on
infrastructure, compared to only 6 percent to 7 percent in Africa.59 This level of funding has also
gradually declined in recent years in Africa. Given the size of additional investments needed going
froward, there will need to be an increasing focus on leveraging innovations (See Appendix 4) to
develop cost-effective, high quality infrastructure.
Private sector investment is limited but increasing. Private sector projects have accounted for
less than 20 percent of overall investment in health service delivery infrastructure. However, they
are steadily growing.
Investments have historically targeted a narrow set of projects, particularly greenfield primary
care infrastructure in the public sector; and brownfield hospital expansions in the private sector. 5
Consequently, considerable funding gaps remain: greenfield secondary and tertiary hospitals;
brownfield upgrades of public sector infrastructure; and critical enablers such as financing,
regulatory framework, data/digital, and health worker training. The exhibit below summarizes the
financial flows from investors into Africa’s health service delivery infrastructure.

XIII
Most of the financing for public sector infrastructure has been provided by DFIs (especially World
Bank, Islamic Development Bank, and AfDB) and bilateral aid agencies (especially Japan, France
and South Korea). Multilateral agencies, including UNICEF, WHO, Gavi and The Global Fund,
also fund health infrastructure projects, mainly focusing on primary level infrastructure and
enablers, through the specific investment amounts are not reported. The Bill and Melinda Gates
Foundation has also financed health infrastructure through grants, with a strong focus on primary
level infrastructure.
Most of the financing of private sector infrastructure has been commercial private investors
(especially private equity funds) and DFIs that have a strong private sector focus. The International
Finance Corporation (IFC) holds the largest portfolio. IFC mainly finances brownfield project for
secondary hospitals and clinics, through loans and equity to private sector developers. Private
equity firms mainly finance high-end facilities that target populations with greater ability to pay,
and brownfield investments as greenfield investments demand more capital and are perceived to
have a longer return profile.

XIV
Annex 7: Lessons on Telemedicine from the Bank’s Medical centre
Telemedicine has been available in some institutions in North, East and Southern Africa for
quite a few years now, but the uptake is very poor.

There are a few issues that are common across the continent.
1) Awareness – this is low. Our citizens are “not aware” or “non-acceptant” of the concept
of telemedicine.
2) Perception – the gross majority of our citizens, including those who are highly educated
do not feel that telemedicine is a form of practicing medicine or an adequate alternative.
They feel the need to be physically clinically touched by medical personnel, in order to
have an accurate diagnosis and subsequent treatment
3) Education and training: There is the need to educate and train both, the recipients of the
services (patients), as well as the providers (medical personnel) and institutions that
provide such services.
4) Infrastructure: Medical, Security and IT infrastructure go hand in hand for this to
succeed. Large parts of our populace either do not have access to smart phones, or do
not have network coverage or do not have the bandwidth necessary for video
consultations. This complicated by high costs for telecommunication services has been
a major stumbling block.
5) Privacy and confidentiality: This is critical for a successful telemedicine. Both the
patient and the doctor need to be assured and acceptable to the privacy / confidentiality
issues raised by this. The US HIPPA rules and the EU GDPR rules are but guidelines,
we need to be able to comply with in order to successfully use this approach. In this
day and age of Social Media – a single misdirected message / communication can have
serious negative implications.
6) Financial aspects: Though initial investments in medical, IT and Security may be high,
in the long run they tend to pay off. This however requires the involvement of other
players, such as insurance companies as well
7) Legal issues: Medicolegal issues are a major issue that needs to be considered. Both the
negative and positive outcomes of telemedicine need to be justifiable – by medical as
well as legal teams.
8) Focus on Basics: Whilst the general idea behind SQHIA is the way to go, a solid
foundation is crucial. We need to learn from the health outcomes in countries with
robust primary health care systems, rather than focus on tertiary systems straight away.
For instance – there is no need to develop the ability to perform cardiothoracic surgery
– if we lack the systems to monitor blood pressure and other basic Cardiovascular
parameters. After all, patients who undergo cardiothoracic surgery will need a robust
system to manage them postoperatively.

XV
Annex 8: The Bank’s track record in Health Infrastructure 1975-2021
AfDB has a long history of investment in the health sector, totalling approximately $5 billion
since inception in 1975, with an initial focus on primary-care facilities and more recently on
secondary and tertiary hospitals. The Bank has supported more than 260 projects in the health
sector, across 51 countries, including 131 projects in health-infrastructure development. The
Bank’s support for health infrastructure was at its highest level in the 1990s, with
approximately $75 million invested annually. Adjusted for inflation, this would be equivalent
to $300 million per year at current prices.

Additionally, the Bank has provided significant support to public-health emergencies,

including approximately $222 million for the Ebola response6 and approximately $4 billion for
COVID-19 health related operations7.

In the private sector the Bank has invested in 2 health focused PE funds and approved a $10
million participation in 2020 in Razorite Healthcare.

Under primary healthcare infrastructure, among the Bank’s projects addressing universal
health coverage, the on-going Building Capacity for Inclusive Service Delivery (BCISD) in
Sudan is improving primary healthcare facilities in selected underserved communities in order
to reduce the risk of people being pushed into extreme poverty. The Government of Sudan’s
work with BCISD in the North Kordofan and White Nile States focuses on antenatal, delivery
and post-natal obstetric services, as well as generally improving maternal, child and
reproductive health services, including immunizations. The Project is improving rural health
center capacity to better meet community health needs. At the beginning of the project, only
19% of primary healthcare facilities in the target states provided essential services. The project
emphasized renovation of health facility infrastructure – providing operating theater,
laboratory and blood bank equipment, as well as e-learning and e-health tools to improve access
and quality of health service delivery to rural poor and vulnerable populations. The project is
rehabilitating and equipping 54 health facilities in Sudan’s North Kordofan and White Nile
States. The project supplied six generators to major hospitals in both states to improve power
supply and delivered six ambulances for evacuations and referrals from far-flung villages to
the main state hospitals. The Morocco Social Protection Improvement Support Programme
(PAAPS) is supporting the rehabilitation, equipping and re-opening of 100 primary health care
facilities (PHCFs) in rural areas in the three target regions (Beni-Mellal- Khénifra,
DraâTafilalet, Guelmim-Oued Noun). The Social Program Support Project in Côte d’Ivoire
approved in 2019 includes the rehabilitation and equipping of 40 first contact health facilities
(PHC). In addition to health infrastructure projects the Bank approved the Senegal Emergency
Community Development Program Support Project in 2018. This included the construction of
20 equipped primary health posts.

Under secondary and tertiary health infrastructure, the Bank through the Improvement of
Health Services Delivery at Mulago Hospital and in the City of Kampala Project (MKCCAP)
in Uganda established two new (each 170 beds) fully equipped national referral hospitals,
expanding access to health care services for the Kampala Metropolitan Area. A third multi-
specialty hospital (Mulago), which is the major national referral hospital, was also extensively

6
This includes $150 million budget support for Côte d’Ivoire, Guinea, Liberia and Sierra Leone.
7
This includes the COVID-19 crisis response budget operations, which focused on health, social protection and
economic policy measures. Specifically, under the health component, the budget support operations aimed at
strengthening policy and regulatory measures to increase testing, tracing, treatment and training and protection of
front-line health workers. However, it is difficult to determine how much of the funding was allocated to finance
these results.

XVI
rehabilitated and equipped; as part of the changes, the intensive care unit was enlarged from 7
beds to 41 beds, of which 27 are adult beds and 14 are pediatric beds. The mortuary was
expanded from 16 to 160 slots; and, the number of operating theatres were increased from 7 to
22. Other changes include the decrease of total beds from 1,500 to 1,000. The project was
planned to contribute to addressing equity in access to specialized health care services,
particularly at Mulago National Referral Hospital. The ongoing East Africa’s Centres of
Excellence for Skills and Tertiary Education in Biomedical Sciences Project Phase 1 is
supporting the creation of a network of Centers of Excellence (CoEs) in biomedical sciences
and engineering – Nephrology and Urology in Kenya, Oncology in Uganda, Cardiovascular in
Tanzania and Biomedical Engineering and eHealth in Rwanda. These state-of-the-art mono-
specialty hospitals are aimed to greatly reduce foreign dependency and expenditures; especially
for Non-Communicable Diseases (NCDs) diagnostics and treatments in Europe, North
America and South Asia. Currently, the EAC Governments and households are utilizing an
estimated USD 150 million annually for NCDs related services from outside the region. The
hospitals will deliver quality research and service delivery through collaboration with ‘World
Class’ institutions.

The Bank also has a track record in the social protection space. The UA 100 million Medical
Coverage Reform Support Programme Phase III in Morocco aimed to improve social
protection and medical coverage for the Moroccan population, particularly the most vulnerable
segments, by extending basic medical coverage and improving access to quality health
services. It helped to establish mechanisms needed to pilot and finance the reform, enhance
social protection coverage for the population, and contribute to providing appropriate and
quality services. The programme helped increase the proportion of the population covered by
a social protection scheme (from 49% to 62%), reduced the share of direct payments in health
expenses, and improved the perception of the quality of health care delivery. In Rwanda, the
Mutuelles de Santé/Community-Based Health Insurance (CBHI) scheme was developed to
meet the needs of Rwandans outside the formal sector, whose access to, and utilization of,
health services had been very low. The scheme has attained coverage of up to 90 percent of the
total population.

With knowledge work, the Bank has developed a Practical Guide on Value for Money in Health
and a tool for assessing public-private collaboration in health at the country level in
collaboration with WHO. The Bank is also currently providing technical assistance on Value
for Money in Health to Madagascar, Guinea, Nigeria and Mauritius.

XVII
Annex 9: External Stakeholder Consultations

Rationale for external stakeholder consultations

The Bank conducted external consultations on the Strategy for Quality Health Infrastructure in
Africa (SQHIA) to confirm its relevance and get inputs in order to refine and sharpen the
Strategy before presentation to the Board. More specifically, the objectives of the consultations
were to (a) to present key aspects of the Bank’s offer in health infrastructure investments and
financing and how we will work with the Governments, Regional Economic Communities
(RECs), other development partners, private sector and civil society to support Africa’s health
systems; (b) hold discussions with the stakeholders and obtain input, comments, and feedback
on the Strategy for purposes of refining and sharpening the document; and (c) Get confirmation
from the Ministers of Health who are custodians of public health in Africa on the relevance of
the strategy for different regions and Regional Member Countries (RMCs).

These consultations were crucial to ensure the delivery of an efficient, impactful and
sustainable strategy. The stakeholders targeted were the Regional Member Countries’
Ministers of Health, Regional Economic Commissions, Senior Health Officials in both public
and private sectors, Health Development Partners, eminent persons and the civil society.

External stakeholder consultations approach

The external stakeholder consultations were held in both physical and virtual formats to
accommodate the limited travel and social interactions occasioned by the COVID-19
pandemic. The launch for consultations of the strategy was posted online and also on all the
Bank’s social media platforms (LinkedIn, Twitter and Facebook) on 22 October 2021,
requesting written feedback.

The Bank team further leveraged the physical meetings of health ministers and officials in two
Regional Economic Communities - the Southern African Development Community (SADC)
from 8-10 November 2021 and the Economic Community of West African States (ECOWAS)
from 8-12 November 2021 to attend in person and consult with regional Ministers of Health
and Senior Officials.

For the virtual consultations, direct emails were also sent to the key stakeholders with the draft
SQHIA document (both English and French versions) by the Vice President for Agriculture,
Human and Social Development (AHVP) to review the strategy document and share their
written comments. Virtual consultations were held on 11 November 2021 for North Africa, on
25 November 2021 for East Africa and Civil Society Partners and on 6 December 2021 for
Central Africa.

External consultation outcomes

Economic Community of West African States (ECOWAS) consultations

• The SQHIA was overwhelmingly welcomed and embraced. The Ministers of Health and
other stakeholders in the ECOWAS region commended the Bank for moving forward with
the SQHIA as a key cornerstone for economic recovery and development after the COVID-
19 pandemic. This is because COVID-19 pandemic found Africa with a very weak
healthcare system, characterized by huge healthcare infrastructure and personnel deficits
with high dependence on importation of pharmaceutical and medical supplies.
• The Ministers of Health and other stakeholders in the ECOWAS region reiterated that with
the adoption of the SQHIA, the continent will witness acceleration of the development of
XVIII
 health service delivery infrastructure to improve the quality of life of people in Africa. In
particular, they were delighted that the SQHIA would ensure that investments in health
infrastructure are packaged with policy dialogue and technical assistance to help ensure
that the capital investments of African countries are anchored in clear national health plans
and financing frameworks to ensure equitable and sustainable health services that are
affordable and accessible, including to poorer and marginalized communities throughout
Africa.
• The Development Partners Group on Health (DPG-H) in Nigeria led by the World Bank,
USAID and the Federal Ministry of Health of Nigeria informed the Mission about the
recently signed Country Compact for the National Strategic Health Development Plan II of
Nigeria, as an Investment Tool. The DPG-H also encouraged collaboration and information
sharing.
• The NSIA and HCF welcomed the SQHIA and informed the Mission that the strategy
aligns very well with the work being done by their organizations. They, however, cautioned
that the private sector is not adequately considered for partnerships. Access to finance is
still also a challenge. They are, however, looking forward to developing strong partnerships
with the Bank in line with the SQHIA.

Southern African Development Community (SADC) consultations

• In their media statement and meeting resolution, the SADC Health Ministers endorsed the
SQHIA, its objectives and strategic thrust on primary health care, secondary and tertiary
care, diagnostic infrastructure, and e-health.
• They further encouraged individual member countries to endorse the strategy and directed
the SADC Secretariat to work with the Bank to explore the possibility of tapping into the
regional financing window to support health infrastructure in the region.

Consultations with Regional Member Countries of North Africa

• All participants expressed that the Strategy is very timely considering the effects of the
COVID-19 pandemic on Africa.
• The representative of Egypt’s Ministry of Health and Population noted that the Strategy
demonstrates the Bank’s willingness to improve the capacities and capabilities of health
systems in Africa, and that the Strategy will support investment opportunities for health
infrastructure in Africa. The Egyptian Ministry of Health also thanked the Bank for creating
a deeply needed platform for policy dialogue through the Strategy, which would support
partnership aimed at improving health infrastructure in Africa, without leaving anyone
behind.
• The Director General of Health of Tunisia welcomed the Strategy and shared that Tunisia
is opening up to the pharmaceutical industry and is making steady progress towards hospital
information services. He noted Africa’s need to develop expertise in digital skills; in
support of the Strategy’s focus on digital health and innovation, the exchange of health
information is key, especially with other countries. Tunisia suggested the development of
a platform to focus on telemedicine.

Consultations with Regional Member Countries of East Africa

• Participants agreed that the Strategy comes at a very important time for the continent, where
we see many African countries actively working on health policy and service reform to
combat the COVID-19 pandemic. Participants were pleased that the Strategy is evidence-
based and has tried to address primary, secondary and tertiary health care, including
diagnostic infrastructure and cross cutting issues like innovation and technology.

XIX
• The Minister of Health from Ethiopia welcomed the Strategy as very comprehensive and it
was excellent to see that the Bank plans to support and align with national health system
strengthening strategies, which are foundational for sustainable development.
• The Permanent Health Secretary of Health for Rwanda appreciated that digitalizion has
been thought of as part of the Strategy, as this is crucial for health service delivery. Rwanda
also noted its appreciation of the Strategy utilizing flexible financing instruments including
Results-Based Financing to promote government ownership and promote sustainability.
Rwanda welcomed the Strategy’s utilization of private investment and asked the Bank to
consider assisting countries to set up environments that attract more private investors into
the health sector. Rwanda is also interested in how the Strategy can leverage the African
diaspora from the professional and financing aspect.
• The Ministry of Health of Uganda and Seychelles’ Ministry of Finance recommended that
the Strategy puts an emphasis on a multisectoral approach to support structures and
processes outside of the health sector that contribute enormously to population health.
Uganda also noted the tremendous opportunity to utilize the digital revolution to tap into
the global health workforce to operationalize health infrastructure in African countries.
This strategy should be closely linked to human resources investments in these countries.
• The Director General of Health of Sudan was particularly interested in how the Strategy
would address primary health services as a pillar to improve the health system and
supported the Bank’s proposed provision of technical assistance in this area.
• The Participants noted other recommendations such as identifying and managing physical,
chemical and economic hazard; the Strategy can support policy coherence to avoid policy
implementation failures in the space of health infrastructure; and as Africa integrates, it is
important that in the design of programs, such as national health insurance mechanisms,
that there is some level of standardization across countries to enable people to consume
health care across borders.

Consultations with Regional Member Countries of Central Africa

• The Strategy was noted as clearly presented and was well received by participants.
• The Minister of Health from Cameroon was happy that the Strategy targets relevant areas
of health on the continent. He added that cardiology is a medical area met with much
difficulty in Africa and could be an area that the Strategy explores. Sub-regional
collaboration could be another area that the Strategy considers, in line with Central African
Ministers of Health agreeing that they need to step up collaboration by thinking beyond
their borders, and to join their expertise to create sub-regional services. The development
of laboratories has been highlighted as a need due to the COVID-19 pandemic and
Cameroon is currently planning to develop a network of laboratories to increase its
diagnostic capacities. He noted that overall, he is happy with the areas of focus in the
Strategy.
• Equatorial Guinea highlighted 2 items to consider for the Strategy: human resources and
maintenance of medical equipment. There should also be more clarity on training of human
resources, and what the responsibility of the Bank is in this regard through the Strategy.
Equatorial Guinea does not have a program to maintain medical equipment, and this is a
major issue for the country, as discovered through an in-depth analysis. Investments in
health infrastructure need to consider the sustainability of its medical equipment and this
could be included in the Strategy. Also, there is a lack of construction companies that
specialize in building hospitals. Hospital infrastructure requires specialized enterprises to
construct them to avoid a down-grade of this type of infrastructure. Meeting this gap will
also improve health infrastructure in Central Africa.

XX
Consultations with civil society partners

• All participants expressed that the Strategy is well-written and designed and that the
Strategy targets gaps in Africa’s health infrastructure and is therefore very timely
considering the effects of the COVID-19 pandemic on Africa’s health systems.
• The Concern Education Health Project (CEHP) believes the COVID-19 pandemic should
be a key element in the Strategy and that emergency health preparation support systems
should be embed into health services. Though the Strategy acknowledges both the public
and private sectors, faith-based organizations should also be considered as they play a role
in health service delivery in various countries. CEHP noted community-based
organizations can play a role in community-led monitoring of the implementation of the
Strategy.
• The African Medical and Research Foundation (AMREF) was supportive of the human
resources, ICT connectivity and WASH components of the Strategy as these were clear
disaster areas demonstrated by the COVID-19 pandemic. AMREF noted the Bank should
consider exploring the establishment of local centers of excellence. As climate change is
becoming a factor against good health, the Strategy should include climate risk analysis
and mitigation measures and align with global climate related actions. The Strategy could
also outline a clear approach for youth engagement as health infrastructure investments
may create avenues for employment for Africa’s large youth population. The role of civil
society organizations could also be more clearly outlined in the Strategy.
• The Sierra Leone Red Cross (SLRC) expressed that the Strategy is well thought-out, has a
great objective, and that the strategic pillars are very realistic. However the Strategy is very
general on proposed health infrastructure investments and should be more specific on the
different country needs. Diagnostic infrastructure is the greatest need in Africa and the
Strategy is very strong on this. SLRC welcomed how the Strategy also puts a focus on
policy dialogue, because none of the strategic pillars would move without policy dialogue.
SLRC also noted that the Bank would face a lot of challenges in implementing the Strategy
without providing technical assistance. SLRC expressed that technical assistance and the
promotion of regional harmonization and collaboration are key in implementing the
Strategy.

Conclusion
The Strategy was generally well received by stakeholders, noting its timeliness and relevance
for the continent, particularly with the effects of the COVID-19 pandemic. Stakeholders
acknowledged that Africa is behind in having quality health infrastructure and had positive
responses to the proposed strategic pillars. They appreciated the strategy’s flexibility in
aligning itself to national health systems and noted the importance of policy dialogue and
technical assistance to successfully implement the strategy. Digitalization was cited by some
participants as the possible game changer to health service delivery in Africa and as a linkage
to the global health workforce, including the African diaspora. Recommendations for
improvement of the strategy included: taking a multisectoral approach to implementing the
strategy to support structures and processes outside of the health sector that contribute
enormously to public health; to consider approaches for maintenance of medical equipment;
and to consider creating an enabling environment for private sector investment in health on the
continent. The main comments/feedback received have been incorporated in the Bank’s draft
SQHIA.

All the three strategic pillars were considered relevant in meeting the varying needs of African
countries with digital health as an important cross cutting theme. The importance of health
insurance coverage in the context of health policy reform to promote equitable access was

XXI
reaffirmed as vital to the functionality and sustainability of the proposed health infrastructure
investments, including to poorer and marginalized communities throughout Africa. The
importance of national health systems strengthening plans to anchor investments and drive
partnerships at country level was reiterated including the key role of private sector and public-
private partnerships (PPPs) in expanding health infrastructure investments. The stakeholders
further articulated the importance of knowledge work, technical assistance and policy dialogue
to accompany infrastructure investments. The SQHIA’s strategic focus was endorsed by the
stakeholders.

Attachments:

• Media statement on the Joint Meeting of the SADC Health Ministers and Ministers
responsible for HIV/AIDS https://www.sadc.int/news-events/news/sadc-convenes-
joint-meeting-ministers-health-and-those-responsible-hiv-and-aids/

• Media statement of African Development Bank’s new health infrastructure strategy

to Health Ministers in Economic Community of West African States
https://www.afdb.org/en/news-and-events/press-releases/african-development-bank-
outlines-new-health-infrastructure-strategy-health-ministers-economic-community-
west-african-states-47043
• Media Interview on the African Development Bank’s Plan to Strengthen Africa’s
Health Infrastructure https://www.youtube.com/watch?v=sW3HaIBrWPU

Notes

1
Namely Power Africa, Feed Africa, Industrialise Africa, Integrate Africa and Improve the Quality of life for the
People of Africa
2
A heavy burden: the productivity cost of illness in Africa. Brazzaville: WHO Regional Office for Africa; 2019.
3
Prioritizing Health: A Prescription for Prosperity, McKinsey Global Institute, July 8th 2020.
4
WASH in health care facilities: Global Baseline Report 2019, WHO and UNICEF, Geneva, 2019.
5
Data from WHO Global Health Observatory.
6
Infectious and parasitic diseases include tuberculosis, STDs (including HIV/AIDS), diarrheal diseases,
meningitis, encephalitis, hepatitis, parasitic and vector diseases (including. malaria), intestinal nematode
infections, and leprosy. WHO: A Heavy Burden; WHO: State of Health in Africa, ISS Africa, WHO Global Health
Observatory.
7
Data based on World Development Indicators, World Bank
8
Data from WHO Global Health Observatory.
9
Fitch Solutions proprietary DALY projections, AfDB.
10
Population 2030 Demographic challenges and opportunities for sustainable development planning, United
Nations, 2015.
11
Africa Economic Outlook 2021 projects that Africa’s GDP will grow by 3.4 percent in 2021 and 4.6% in 2022.
after shrinking by 2.1 percent in 2020 because of the COVID–19 pandemic.
12
Population 2030 Demographic challenges and opportunities for sustainable development planning, United
Nations, 2015.
13
CDC Africa, 2020.
14
The economic impact of the 2014 Ebola epidemic: short- and medium-term estimates for West Africa, World
Bank Working Paper, October 2014.
15
“Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-
income countries: a modelling study”, Hogan, AB. et al, The Lancet, July 2020.
16
Second round of the national pulse survey on continuity of essential health services during the COVID-19
pandemic, World Health Organisation, April 2021.

XXII
17
Comorbidities and the COVID-19 pandemic dynamics in Africa, Anjorin, A.A. et al, Tropical Medicine and
International Health, October 2020.
18
The COVID-19 syndemic is not global: context matters”, Mendenhall, E, “The Lancet, vol. 396, November
2020.
19
The African Economic Outlook 2021 predicts that Africa’s GDP will grow by 3.4% in 2021.
20
Global Economic Prospects, World Bank Group, June 2021.
21
Urgent, effective action required to quell the impact of COVID-19 on education worldwide, World Bank,
January 2021.
22
The Impact of COVID-19 on African Economies: An Introduction, Anyanwu, J.C. and Salami, A.O. African
Development Review, 2021.
23
This based on a framework published by the World Health Organization in 2014.
24
Data from WHO Global Health Observatory.
25
Poor availability of essential medicines for women and children threatens progress towards Sustainable
Development Goal 3 in Africa, Droti, B. et al, BMJ Global Health.
26
Data from WHO Global Health Observatory.
27
According to a recent research (“National estimates of critical care capacity in 54 African countries”, Craig, J.,
Kalanxhi, E. and Hauck, S., 2020) The average number of ICU beds per 100,000 people ranges from 0.53 in low-
income countries to 8.59 in upper-middle countries.
28
International cancer control portal, India country report, International Cancer Control Partnership, 2020.
29
“Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded
inventory and spatial analysis”, Ouma, P.O et al, The Lancet, January 2018.
30
WASH in health care facilities: Global Baseline Report 2019, World Health Organization (WHO) and the
United Nations Children’s Fund (UNICEF), 2019.
31
WHO/World Bank report “Access to Modern Energy Services for Health Facilities in Resource-Constrained
Settings”. One in 4 health facilities was found without access to electricity.
32
COVID-19 testing in Africa: Lessons learnt, Ondoa, P. et al, The Lancet, July 2020.
33
Data sourced from WHO Country Reports.
34
A 2017 study (Service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal,
Rwanda, Senegal, Uganda and the United Republic of Tanzania, Leslie, H.H. et al) found that in 10 countries -
including 7 in Africa - only 14% of hospitals and 1% of health centres/clinics were attaining 100% readiness for
basic diagnostic capacity.
35
The WHO reports (in The state of health in the WHO African Region, 2018) that the density of laboratory health
workers in the WHO African Region ranges from 0.002 per 1,000 people in Sierra Leone to 0.341 in Sao Tome
& Principe.
36
These are estimates calculated by the African Development Bank.
37
Delivering quality health services – A global imperative for universal health coverage, WHO, 2018.
38
This data is from the Primary Healthcare Performance Initiative 2020.
39
World Development Indicators (Current health expenditure, % of GDP).
40
These aggregates were calculated by the African Development Bank.
41
This is based on the original figure of $44, calculated in 2010 by the Taskforce on Innovative International
Financing for Health Systems, adjusted for inflation.
42
These aggregates were calculated by the African Development Bank.
43
This data is sourced from the WHO Global Health Observatory.
44
This data is sourced from the WHO Global Health Observatory.
45
This is an estimate calculated by the African Development Bank.
46
African Economic Outlook 2021, African Development Bank, 2021.
47
Comparing the role of Diaspora in expansion of marketed healthcare in China and India: 1950s to present,
Zafar, S, Jawaharlal Nehru University, 2014.
48
South Asia Migration Report 2017: Recruitment, Remittances and Reintegration, Rajan, S.I, Taylor and Francis,
November 2016.
49
Estimate based on a combination of multiple sources: media reports, expert interviews, World Bank data on
capital health expenditure and the WHO Global Health Observatory.
50
OECD Stat CRS Aid Activity database.
51
Use of social impact bonds in financing health systems responses to non-communicable diseases: scoping
review, Hulse, E. et al. BMJ Global Health, 2021. However, note that in the context of COVID-19, AfDB launched
the largest social bond ever in February 2020, for a value of $3 Billion.
52
Data compiled by the Bank.

XXIII
53
Mixed effects analysis of factors associated with health insurance coverage among women in sub-Saharan
Africa, Amu, H. et al, PLOS ONE, March 2021.
54
The Business of Health in Africa: Partnering with the private sector to improve people’s lives, World Bank
IFC, 2008.
55
This is based on the WHO’s conceptualisation of health systems having six building blocks.
56
The proportion of Bank finance for infrastructure which is focussed on such complimentary support such as
policy reform, technical assistance and knowledge work varies from an average of 10% in the transport sector, to
15% in the energy sector, and 25% in water and sanitation sector.
57
“Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded
inventory and spatial analysis”, Ouma, P.O et al, The Lancet, January 2018.
58
WHO (State of health in Africa report 2018) benchmarked that 33% of public health expenditure should go to
infrastructure, while UNECA (Healthcare and economic growth in Africa 2019) sized the public health
expenditure gap at $66 Bn, 33% of which is $220 Bn for the next 10 years. This does not consider the need to
close the existing infrastructure gap hence the higher estimate of $260Bn.
59
Based on press search, expert interviews, IFC, World Bank, WHO Global Observatory Database, and WHO State of
Health.

XXIV