FINAL REPORT ASSESSMENT OF HEALTH RELATED INVESTMENT AND FINANCING OPPORTUNITIES IN

Financing Growth Work Order 2014-03 Contract No. AID-EEM-E-00-08-00002 Order No. AID-OAA-BC-14-00030

March 2015

This document was prepared by Banyan Global under Financing Growth: Assessment of Health Related Investment and Financing Opportunities in Senegal.

ASSESSMENT OF HEALTHCARE RELATED INVESTMENT AND FINANCING OPPORTUNITIES IN SENEGAL

FINAL REPORT MARCH 2015

Contract No.: AID-EEM-E-00-08-00002 Order No: AID-OAA-BC-14-0030 Work Order No. 2014-03

Submitted to: Lawrence Camp, COR Director USAID, Millennium Challenge Corporation

DISCLAIMER The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government. PROJECT OVERVIEW

Financing Growth: Assessment of Healthcare Related Name Investment and Financing Opportunities in Senegal

Contract Number AID-EEM-E-00-08-00002

Order Number AID-OAA-BC-14-0030

Work Order Number 2014-03

Start Date January 21, 2015

End Date February 28, 2015

Geographic Coverage Senegal

Quarterly Progress Report #1, October - December 2014 CONTENTS

Acronyms...... i 1. Introduction ...... 2 2. Project Tasks and Activities ...... 3 2.1 Task I: Collect Secondary Data on the Private Health Sector in Senegal ...... 3 2.2 Task II: Identify Information Gaps to be Filled in Through Local Research...... 3 2.3 Task III: Develop a Framework Spreadsheet Model to Assess Opportunities ...... 5 2.4 Task IV: Develop Market Projections...... 6 2.5 Task V: Identify Financial Institutions...... 7 3. Key Findings ...... 8 3.1 Characteristics of Health Private Sector in Senegal...... 8 3.2 Health Market Characteristics...... 9 3.3 Facility Owners...... 9 3.4 Facilities...... 10 3.5 Business Management and Financing...... 10 3.6 Four Market Segments...... 10 3.7 Market Segementation ...... 11 3.8 Financial Needs and Willingness to Borrow...... 11 3.8.1 Assumptions and Analysis...... 11 3.8.2 Summary of the Market Opportunity...... 13 3.9 Additional Information and Observations...... 13 4. Constraints and Limitations ...... 15 5. Recommendations and Steps Forward...... 16 Annex A: Summary of the Secondary Data Review ...... 17 Annex B: Framework Spreadsheet ...... 21 Annex C: Private Sector Survey...... 22 Annex D: List of Private Health Facilities Interviewed ...... 29 Annex E: Profiles of Key Private Healthcare Facilities...... 30 Annex F: Health Lending Opportunities in Senegal: Summary of the Projections...... 33 Annex G: Model Calculations for Senegal ...... 37 Annex H: List of Financial Institutions Interested in Health Lending...... 38 Annex I: Exit Debriefing with USAID Senegal ...... 39

Quarterly Progress Report #1, October - December 2014 ACRONYMS

ADEMAS Agence de Développement du Marketing Social CFA Communauté Financière d’Afrique DCA Development Credit Authority DHS Demographic Health Survey E3 Bureau for Economic Growth, Education, and Environment (USAID) EIF European Investment Fund FI Financial Intermediaries GOS Government of Senegal HLT Health Lending Toolkit IFC International Finance Corporation IMP Institution de Prévoyance Maladie MFI Micro Finance Institutions MOH Ministry of Health MOHSA Ministry of Health and Social Action MPEP Office of Microenterprise and Private Enterprise Promotion (USAID) ONMS Ordre National des Médecins du Sénégal PPP Public Private Partnership SHOPS Strengthening Health Outcomes through the Private Sector Project USAID U.S. Agency for International Development

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal i 1. INTRODUCTION

The USAID-funded Assessment of Health Related Investment and Financing Opportunities in Senegal under the Financing Growth project conducted a rapid review of current and projected healthcare lending opportunities in Senegal. The assessment was undertaken to analyze the current market demand for financing from the health sector and develop a presentation of the data that could facilitate a go/no- go decision by financial intermediaries exploring whether to pursue lending to this sector.

The E3 bureau, in conjunction with the Global Health Bureau through the SHOPS project, had developed a Health Lending Toolkit (HTL), which is designed to support financial institutions in:

 Phase One – determining whether healthcare lending (primarily private clinics and pharmacies) is a profitable lending market for them; and if so,  Phase Two – Developing a healthcare lending program and products with which to pursue the opportunity identified.

The premise of the HLT is that obtaining a real commitment from a financial intermediary to enter into a specialized lending area - such as healthcare - is contingent upon that institution having made an evidenced-based decision about the market opportunity. Financial intermediaries (FIs) may seek technical assistance or partial guarantees from USAID, but too often the guarantee remains under- utilized. This is partially a result of FI’s lack of understanding about the opportunities in the health sector due to limited pre-assessment and analysis of the sector. As such, a key element of the Healthcare Toolkit is to work with FIs to obtain the market data they need to make a go/no-go decision based on the lending opportunities in their catchment area. Once that decision is made, the FI needs to make the institutional investments needed to enter into this targeted area.

The USAID Senegal Mission expressed interest in hosting a beta test of the HLT in Senegal, of which the current project constitutes phase one. Phase two will be undertaken based on interest from local financial institutions.

The project team for the assessment included Mr. Piotr Korynski, Senior Associate at Banyan Global, who traveled to Senegal from February 9-19, 2015. Mr. Korynski was supported by a Senegalese health systems expert, Mr. Daouda Mbengue.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 2 2. PROJECT TASKS AND ACTIVITIES

This project involved the review of secondary data, a rapid assessment of current and potential healthcare lending opportunities in Senegal, and a presentation of the data in a format which could facilitate a go/no-go decision by a financial intermediary.

2.1 TASK I: COLLECT SECONDARY DATA ON THE PRIVATE HEALTH SECTOR IN SENEGAL

The project reviewed the secondary data on the private health sector in Senegal to ascertain the amount and type of information that is already available. As expected, some information is available through the Demographic Health Survey (DHS) data base, which in Senegal is updated annually, and specific reports and assessments that focused on the private sector healthcare market. A short summary of the secondary data reviewed is included in Annex A.

2.2 TASK II: IDENTIFY INFORMATION GAPS TO BE FILLED IN THROUGH LOCAL RESEARCH

The review of the secondary data revealed that there are serious gaps in information that are needed to accurate determine the demand for healthcare lending in Senegal. These gaps include:

 Number of providers  Geographic distribution  Size and scope of healthcare businesses  Financial needs of providers  Willingness and ability to access external financing, including banks  Interest in growing their practices  Current use of financial services

Such information is typically not available in existing sources because it is not collected by the Ministry of Health (MOH) or the National Statistical Office as it must be collected through interviews with providers. Information about business and financial performance is deemed confidential and providers are reluctant to share such information with researchers, for fear, among other things, that it may be leaked to the tax authorities and other government bodies.

Two sources of data collection were used to collect primary data: interviews and stakeholder workshops. The project team developed a rapid assessment tool using the materials and approaches suggested in the Health Lending Toolkit to acquire information from private . The

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 3 interview protocol was coupled with a checklist for group discussions. Please see Annex C for the private sector survey used during the interviews.

The choice of the sample was guided by information gathered from the MoH, USAID and general sector knowledge regarding location, clinic sizes and range of services offered. Final decisions regarding which providers to interview made based on suggestions from the Médecin Chef de District where providers were located.

In total, 33 providers were interviewed in 4 Medical regions (, Thiès, Dioubel and Saint Louis). 4 private providers were interviewed in each region and the rest in Greater Dakar. Table 1 summarizes the sample composition of the interviewed providers. The list of private providers interviewed is presented in Annex D.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 4 Table 1: Rapid Assessment of Healthcare Facilities by Type and Location

Type of Facility Dakar Thiés Dioubel Saint Louis Total

Hospital 0 2 0 0 2

Clinic 7 1 2 1 11

Cabinet (Doctor’s 7 2 1 3 13 Office)

Pharmacy 2 0 1 0 3

Laboratory 2 0 0 0 2

Equipment supplier 2 0 0 0 2

Drug Manufacturer 1 0 0 0 1

Total 20 5 4 4 33

In addition to the interviews of providers, other stakeholders were met to cross check findings and to discuss general opportunities and constraints within Senegal’s private health sector. In this purpose, the field team met with the MOH (PPP adviser), Ordre National des Médecins du Sénégal (ONMS), IntraHealth, Agence de Développement du Marketing Social(ADEMAS), Marie Stops International, Abt Associates, and Pfizer.

Based on its interviews, the field team developed business profiles of key private sector facilities that are most likely to borrow funds from banks and other financial institutions: hospitals, clinics and private cabinets. These profiles can be found in Annex E.

2.3 TASK III: DEVELOP A FRAMEWORK SPREADSHEET MODEL TO ASSESS OPPORTUNITIES

The project team constructed a spreadsheet template model for assessing the current and potential lending opportunities in Senegal’s health sector. The model is based on key variables and assumptions related to the growth of the private health sector and potential financing needs in the next five years. The spreadsheet-based model captures the current health sector demand and potential future opportunities in four key healthcare related market segments and offers a baseline as well as future demand for funds.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 5 Purpose The model assesses the private health sector lending opportunities that exist in a particular market at present and in the foreseeable future (assuming a 5 year time horizon). As such, the model is an approximation or an informed guess as to how the private healthcare market may evolve under the assumptions that guide the model. The model is of a static nature although it allows the user to change the underlying assumptions and input variables and create different scenarios regarding various future opportunities.

Assumptions The model works on a number of assumptions about Senegal’s private health sector and general conditions of health sector development. In particular, it assumes there to be four market segments of the healthcare sector, namely: (1) health services delivery market, (2) pharmaceutical value chain, (3) equipment and medical supplies value chain, and (4) health education market.

In addition, the model assumes that the growth of the healthcare market is driven by the growth of the healthcare workforce engaging in the private sector (as the workforce is the limiting factor in the emerging economies), and by the growth in revenue allocated to health which is impacted by the public and private expenditures on health. It is further assumed that a portion of public and a portion of private expenditures contribute to the revenue of private providers, regardless of whether they are directly or indirectly channeled to the private sector providers. Last but not least, the model realistically assumes that only a portion of providers have needs for financing, and only a subset of them will be willing to borrow and succeed in obtaining banks loans.

Inputs The model requires a set of inputs which relate to the behavior of the private healthcare businesses in relation to their intention to expand and their willingness and ability to use external financing to achieve these goals. These inputs must be inserted in the gray shaded cells of the "Inputs' worksheet. All inputs must be provided for the model to work.

Outputs The model output is provided in the "Lending Opportunity Summary' tab which summarizes the estimate for the potential lending market available to financial institutions in a given market, shown by different types of financing (working capital, equipment financing an facility improvements and expansion)and different sub-sectors of the market. The outputs are presented in a table and visually in a set of graphs. The framework spreadsheet is attached in Annex B.

2.4 TASK IV: DEVELOP MARKET PROJECTIONS

Using the framework model with inputs collected through secondary data research and field interviews with providers and other stakeholders, the team developed a set of lending opportunity projections in Senegal’s private health sector.

The results are presented in Annex F (Summary of Projections) and Annex G (Spreadsheet Model).

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 6 2.5 TASK V: IDENTIFY FINANCIAL INSTITUTIONS

The field team was able to work closely with USAID Senegal on the identification of prospective FIs to test the Toolkit. A Development Credit Authority (DCA) team had recently interviewed a number of banks and microfinance institutions (MFIs) in Senegal based on USAID/Senegal’s interest in pursuing a DCA. As such the short list of these FIs proposed by DCA for USAID consideration is attached in Annex H.

Annex I contains the exit debriefing presentation to USAID/Senegal at the end of Mr. Korynski’s trip to Senegal.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 7 3. KEY FINDINGS

3.1 CHARACTERISTICS OF HEALTH PRIVATE SECTOR IN SENEGAL

The private health sector providers can be divided into 4 categories: (1) large facilities, (2) paramedic clinics and cabinets, (3) medical clinics and cabinets, and, (4) the pharmacy industry. These are described below.

 Hospitals, large clinics, laboratories and equipment suppliers: comprise the largest facilities. They each serve over 25,000 clients a year with annual revenue of approximately 250,000,000 CFA ($500,000). They are organized as limited liability companies and typically are well established. They employ sizable staff, sometimes over 100 clinical staff. They are, on average, more than 10 years in operations. They have built bank relationships and they are financially stable. There could be demand from this sector for those seeking to expand or diversify current facilities.

 Paramedic clinics and cabinets: are often solely owned. Almost all of the owners have retired from the public service before opening their own private business and do not have business banking relationships. Those who have borrowed use their pension has a guarantee. This segment of the health sector serves between 700 to 2,500 clients a year with revenues comprised between 4,000,000CFA ($8,000) to 73,000,000 CFA ($145,000). According to the Ministry of Health (MoH), they represent 15% of the private sector providers. Opportunities for lending include young entrepreneurs who want to open facilities and have financial needs and a willingness to borrow to launch their business.

 Medical clinics and cabinets: are mostly specialized but also offer general medicine services. Cabinets are usually solely owned while clinics are limited liability companies. This health sub- group serves between 1,500 and 9,000 clients a year with revenues ranging from 18,000,000 CFA ($36,000) to 150,000,000 CFA ($300,000). This group represents 78% of the private health sector. They have bank relationships but sometimes experience difficulties in gathering the required collateral required by FIs. Like large clinics, they face cash/flow problems due to arrangements with insurance companies, the Institution de Prévoyance Maladie (IMP) and late payments for services provided. Their financial needs vary from 20,000,000 CFA ($40,000) to 250,000,000 CFA ($500,000). Some businesses have very clear projects and are actively looking for funding.

 Pharmacies: they are cash-and-carry businesses and solely owned. At startup they usually have a line of credit with wholesalers. Currently, there are 1,013 pharmacies in Senegal. On average they serve 15,000 clients a years with revenue around 60,000,000 CFA ($120,000). They have bank relationships but no need for debt financing unless they diversify.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 8 3.2 HEALTH MARKET CHARACTERISTICS

The private health market in Senegal is vibrant and plays an important role in the economy. However, the market is mostly limited to large urban areas serving better off populations. The following are some of the key features of the private health market in Senegal:

 The private health sector is profitable and attracts new entrants, although new entrants are finding it more and more difficult to find profitable niches. New clinics locate in newer neighborhoods of Dakar where the population is less affluent.  Private health is complementary to the public sector but still not well integrated into the national health system. The private health sector mostly serves more well-off populations although there are many that provide services to lower income populations. .  There is a fundamental market mismatch in Senegal regarding the largely underserved rural areas and unemployed workforce in Dakar seeking work.  Most of the revenue generated in the private sector is out of pocket. About 10% of its revenues are reported to be lost because of the inability of clients to pay fees.  Late payments from insurance companies that may last for several months necessitate bank overdrafts to help the facilities manage their cash flow.  There is large unemployed and underemployed workforce of the private healthcare market.  Lack of liquidity at the household level in rural areas is a constraint to the private clinics locating in these areas.  In some areas the private health market is saturated, e.g., center of Dakar while others are underserved.  Data on the private healthcare market is incomplete and not easily available. Various sources have different numbers in terms of clinics, locations, revenue and other indicators.

3.3 FACILITY OWNERS

Private health facilities are owned predominantly by health professionals, the majority of whom are well advanced in their careers, and often retired from the public service. The following are some of the observations pertaining to the owners:

 To be successful, professionals need substantial experience in the medical profession (e.g., 10 years), which is gained mostly in the public sector. This is one of the reasons why health workers start their private practices later in their professional career, often after retirement.  While some doctors may be of working age, paramedics are almost exclusively retired. They may face the most significant credit constraint.  No succession plans exist for older doctors. However, given the ageing population of many owners there is risk that a number of facilities will soon close.  Paramedics and midwives usually seek partnerships with doctors as a more feasible way to work in private practice.  Gynecologists are the driving force for many private businesses; their services are in great demand and are very lucrative. Many private practices are established around or in conjunction with gynecologists.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 9  Not all specialists can maintain ‘pure’ specialty practice and work as generalists in addition to their specialty as there may not be enough demand for the specialty medical service offered.

3.4 FACILITIES

Senegal does have modern health facilities with state of art equipment as well as very basic clinics; each type could be a candidate for bank financing but with a different range of financing needs. Some observations from the field assessment are as follows:

 Private facilities are under-utilized although many clinics also have somewhat long waiting times due to overall inefficiencies. Technical assistance to private facilities could make significant improvements to streamline services, increase revenues and overall profitability.  Quality of service is an issue; older healthcare workers may not be up-to-date with the new protocols and routines. Older facilities may not be as well-equipped as newer ones and may not offer a full range of services.  Because of credit constraints, some of the owners initiated the construction of facilities with their own resources and were unable to complete them.  Hospitals are non-profits and managed by churches; there are no private for-profit hospitals in Senegal.

3.5 BUSINESS MANAGEMENT AND FINANCING

Business management and entrepreneurial vision varies greatly among the providers. A few salient points from the field assessment include:

 There are providers who have a vision for expansion, with specific plans and are actively looking for funding.  Many facility owners are reluctant to borrow funds from banks although their business could benefit from financing; the reasons for this need further investigation.  Many providers who have been in business for a number of years have personal (not professional) banking relationships; as a result, older clinic owners borrow against their pensions and savings.  Not all clinics and cabinet owners have the necessary skills to manage private business; many need professional accounting and management assistance.

3.6 FOUR MARKET SEGMENTS

During the field assessment, a review was undertaken of the current state of the private health market. Four key market segments appear to describe this market:

 Older and established cabinets and clinics (65%) • Fairly well established, less prone to grow, could face succession issue, opportunity to match with younger / unemployed pool, low need for external financing.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 10  Newer facilities (less than 10 years) looking to grow (35%) • Need to improve quality in the increasingly dense market / most likely segment to borrow.  Recent start-ups / early stage businesses • Unknown number, often not registered with Ordre des Medecins, likely to need funding.  Potential start-ups • Large healthcare projects (e.g., cancer hospital, laboratory, etc.). • New health businesses started by the unemployed workforce (no resources to start, less experience because of unemployment, no collateral to borrow).

3.7 MARKET SEGEMENTATION

All stakeholders interviewed for this study indicated the general stable and important role of Senegal’s private health sector. Most predicted continued growth of the sector to meet the country’s growing population. The growth will depend on two main factors: (1) ability of the urban population to pay for services, and (2) ability of the government to generate revenue through the universal health coverage in the rural areas where the need and demand is the biggest. There are a few key factors that frame the private health market:

 The private health sector market is growing and the recent rate of growth appears to be high: • Growth has been almost exclusively in the urban areas • Not all providers are registered / authorized to operate, which limits their ability to borrow funds from banks  There has been a growth boom in the pharmacy segment, driven by lucrative opportunities and a significant push from pharmaceutical companies (e.g., Pfizer, Novartis). For example: • There are currently 1,013 pharmacies vs. 700 in 2014 • Pharmacies are mostly financed through wholesalers  There has been a large increase in cabinets and polyclinics although the extent of this growth is unknown.  There is a large unemployed pool of healthcare workers (5,000 professionals: 500 doctors, 3,000 midwives and 1,500 nurses). This could be a great opportunity to expand health clinics into rural areas if there is seed capital for new start-ups.

3.8 FINANCIAL NEEDS AND WILLINGNESS TO BORROW

3.8.1 ASSUMPTIONS AND ANALYSIS

While it is difficult to assess the actual financial needs and effective demand for bank financing, the following is an approximation of the financial needs in Senegal based on the willingness and ability to borrow (calculated with the use of the model described in 2.3 and 2.4). The main financial needs in terms of the type of financing are as follows:

 Premises  Equipment

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 11  Overdraft for cash needs  Upgrade of business type (from a cabinet to a clinic)

In terms of willingness to borrow, no clear picture emerges from the field assessment’s interviews with the providers (see Table 2). In summary:

 Labs, some cabinets and large clinics want to borrow  Older clinic owners have less interest in borrowing  Those in greatest need to borrow may not have the capacity to borrow, in particular younger and unemployed healthcare workers

Table 2. Ability and Willingness to Borrow

Willingness to Borrow

Yes No

Hospitals, established clinics and newer growth Older and well established cabinets,

Yes oriented cabinets pharmacies

Newer and smaller cabinets, esp. by paramedics X No Ability to Borrow

As far as the amounts and percentage of facilities willing to borrow, it appears that hospitals are most likely to borrow and their needs are higher. The following summary shows that almost all hospitals are potential borrowers while only 50% of clinics, 10% of cabinets, and 10% of pharmacies may have a viable business proposition from which to request a bank loan.

 Hospital (100%): • Larger: 150,000,000 CFA ($300,000) • Smaller: 80,000,000 CFA ($160,000)  Clinique privé (50%): • 20,000,000 – 2,000,000,000 CFA ($40,000 - $4,000,000)  Cabinet medical (10%): • 10,000,000 - 50,000,000 CFA ($20,000 - $100,000)  Paramedical (10%): • 5,000,000 - 20,000,000 CFA ($10,000 - $40,000)

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 12 3.8.2 SUMMARY OF THE MARKET OPPORTUNITY

Table 3 summarizes the current market opportunity at about $11 million USD annually, which realistically may be less given the fact that not all potential borrowers would qualify for a bank loan. This is a result of normal bank policies and processes that require financial statements, collateral and sometimes fairly high interest payments making it difficult for interested health businesses to successfully secure a loan.

Table 3: Summary of the Current Lending Opportunities in Senegal

Type of Facility Potential Realistic Amount Amount Amount under DCA

Health Services Delivery Market $9,500,000 $6,750,000 $4,500,000

Pharmaceutical Value Chain $1,000,000 $750,000 $500,000

Equipment and Medical Supplies Value Chain $500,000 $500,000 $500,000

Total $11,000,000 $8,000,000 $5,500,000

It should be noted that that this seemingly low amount of borrowing potential should be supplemented with the already on-going bank financing of the sector. Therefore this estimate should be understood as supplemental to FI’s ongoing lending to the private health sector. In addition, there are several larger projects in the market (such as a cancer hospital) which would require larger amounts of financing; however, these projects are likely to be financed by social investors and donors such as International Finance Corporation (IFC) or European Investment Fund (EIF).

3.9 ADDITIONAL INFORMATION AND OBSERVATIONS

From the collected data, it appears that those who are in need (young providers) of financing are less able to borrow due to their lack of bank relationships, financial acumen, and collateral. In a short time if this has not been corrected, only large clinics and cabinets will occupy the market as new entrants will be limited and older providers will no longer be active.

In interviews with providers, most are also concerned about high interest rates banks are charging. This is interesting to note, as interest rates in Senegal are low in comparison with other countries in West Africa. This verifies a need for financial literacy and financial management training of health care providers to understand their own profitability and the benefits from borrowing.

In some parts of Senegal, the development of the private health sector is stalled by peculiar local problems. In Touba, regulation of the pharmacy sector is a main concern because of its special status as a religious city; there is no need to be a trained and licensed pharmaceutical professional to run a pharmacy. The black market for drugs is very strong and illegal pharmacies operate side by side with licensed ones.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 13 Capacity building is needed from the providers’ point of view. On top of financial needs, private providers need technical assistance on financial and human resource management and in accounting. This will help them to do the business more profitable.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 14 4. CONSTRAINTS AND LIMITATIONS

The project encountered several challenges and limitations in completing the activities set forth in the work plan and scope of work which relate specifically to testing of the Health Lending Toolkit.

Developing a Projection Model for the Private Health Sector

The project model proved to be more challenging than was anticipated due to several reasons. Private health is a part of the overall health system and plays a complementary role to the public health. For that reason Senegal’s private sector reacts rather than leads and adjusts to the supply offered by the public sector. Health is also a highly regulated industry and does not operate purely on market principles; to a large degree the government decides on the size and scope of the private sector, directly or indirectly, and such political decisions difficult to predict.

These factors impose strong limitations on the ability to model the future behavior of private providers and consequently, their ability and willingness to borrow funds for expansion and growth. The proposed model helps to calculate the potential demand for financing based on the assumptions about future growth; however these assumptions may not necessarily correctly represent the likely growth pathway of the private health sector. Therefore, the results should be interpreted with caution.

Availability of Secondary Data on Private Health

Less data on the private sector was available than was originally assumed. Data that is available is inconsistent and contested by all stakeholders. For example, the Ministry of Health’s data base shows only about 600 private providers in Senegal although they believe that there are more. Data on financial performance of private providers is also not available through secondary sources.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 15 5. RECOMMENDATIONS AND STEPS FORWARD

Given the limited scope of this assessment and the need for a more in-depth understanding of Senegal’s private health sector, the following next steps are recommended:

 Conduct additional research on the subset of Senegal’s private healthcare market currently supported by USAID to enable a more nuanced understanding of the levels and types of anticipated borrowing demands. Field-based interviews should be conducted with:

• BlueStar /Marie Stopes International Franchise Networks • ADEMAS Network • IntraHealth Network

 Review the capacity of USAID’s proposed banks to develop a health-focused loan product and design a technical assistance package for the bank(s) that will address existing institutional knowledge and skill gaps.

 Support the DCA banks with technical assistance to develop financial products for Senegal’s private health sector.

 Explore the design of a project to build the capacity of the private health sector in financial and business management skills to strengthen their understanding of the benefits (and risks) of borrowing and how to leverage funds to diversify and grow.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 16 ANNEX A: SUMMARY OF THE SECONDARY DATA REVIEW

Background Research on Senegalese Private Healthcare Sector

Services Provided

 4 private hospitals (Abt Study, 2014)  43 private health clinics (Abt Study, 2014) • Usually run by 2-3 doctors • Offer a wide variety of services, including in patient care  259 private Postes de Santes (health posts) (DHS, 2012) • Health posts are staffed by nurses and midwives. • They provide care for common illnesses, pre- and post-natal care, routine deliveries, and health education and counseling. • While public-sector nurses are authorized to write prescriptions, those in the private sector are not, so private health posts cannot legally prescribe any medicine, they can only provide care. However, many private nurses write prescriptions despite regulations against it. • Private health posts are well integrated with the public sector  1,506 Cases de Santes (health huts) (DHS, 2012) • Run by community health workers who are trained to provide basic services, counseling, and education . Run the middle ground between private for profit and government healthcare. They are often funded by charitable organizations and international NGOs • Health huts are often the only accessible facilities in rural areas • Although not part of the public healthcare sector, the GOS recognizes their importance and works well with them  Over 700 private pharmacies (SHOPS Assessment, 2009) • Pharmacies are often the first form of healthcare sought out in Senegal • Public insurance does not cover the cost of medication, so it’s safe to assume most all medication expenditures are out of pocket • Smaller Depots de Pharmacie (pharmacy depots) also exist, but aren’t well regulated and there is not quality assurance in place. As such, there isn’t much data on these depots and the GOS has started to attempt to reduce their numbers.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 17 This graphic illustrates the structure of the private sector healthcare network with the highest care facilities towards the top and the facilities with the least amount of services at the bottom.

Hospitals

Private Clinics

Cabinets Médicaux

Postes De Sante Infirmiers

Workplace Clinics Cases de Santes

Pharmacies Depots de Pharmacie

Location & Demographic The private health sector is concentrated in Dakar, where about 85% of all private healthcare providers are located.

 In a 2011 ILO survey of rural access to healthcare, respondents stated that they had little access to private healthcare  A 2009 SHOPS assessment found little likelihood of private healthcare expansion to rural areas, citing lack of market opportunities outside of major cities due to low rural incomes and population density.

About 2/3 of all private pharmacies are found in Dakar, but they also exist in rural areas.

The majority of private healthcare clients are covered by private health insurance provided by their employers. Those who aren’t covered by private insurance have trouble paying the fees imposed by private, for-profit institutions, thus the private sector’s demographic is limited to those with high- incomes or private insurance (SHOPS assessment 2009). This demographic is small, because only roughly 23-28 percent of the population is currently covered through the countries varies insurance pooling schemes (Abt Report, 2014).

Governance of public healthcare and engagement with the private sector

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 18 Healthcare governance is marked by a decentralization policy that places responsibility for public healthcare on local municipalities and rural communities. These decentralization reforms have created more opportunities for efficient local public and private sector engagement; however, despite being in place since the 1990s, the policy is not fully implemented and the transfer of power from central to local governments is still a work in progress. The GOS also has a contracting-out policy designed to involve the private sector with the public healthcare. This encourages public-private partnering. (Abt report 2014)

Healthcare Spending & Financing In 2011, Senegal spent 5.98 percent of its GDP on healthcare which translated into US$119 per capita. The private sector accounted for 43% of total healthcare expenditures (Abt. report 2014).

Households directly contribute 37.6% of total healthcare financing, with 89% of their costs going to out of pocket spending and 11% going towards health insurance payments.

Healthcare Demands The GOS, WHO, and USAID have placed an emphasis on maternal and child . The Senegalese government has committed itself to lowering the country’s infant and rates. As of 2012, the rate was 47 per 1,000 births and the child mortality rate for children under 5 years old was 65 per 1,000 births. 95% of women (99% in urban areas, 92% in rural) consulted a healthcare professional during their most recent pregnancy and 71% of births take place in health facilities.

Despite efforts by USAID to promote family planning in Senegal, modern contraceptive usage is low, with only 16% of women using a modern contraceptive method. The Senegalese fertility rate remains high at 5.3 (4.1 in urban areas and 6.3 in rural). This high fertility combined the push for reduced infant and child mortality rates suggest a high demand for pre and post natal as well as pediatric care.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 19 Private Sector Expansion There are few governmental or bureaucratic barriers to private sector expansion. The process of opening a private health facility is straightforward and the requirements can be accessed on the MSP’s website.

Financial costs and constraints, however, present serious barriers to private healthcare expansion. Large amounts of capital are needed in order to open private healthcare facilities, and providers often have trouble obtaining credit because banks place large collateral requirements on their loans. In order to overcome this obstacle, the Syndicat de Médecins Privés has negotiated deals with two banks to provide loan assistance to private healthcare providers and established a fund to prevent providers from defaulting (SHOPS Assessment 2009).

The lack of purchasing power presents a roadblock to private healthcare expansion. The GNI per capita in terms of PPP is only US$1,830. Because the majority of the population is uninsured and out of pocket costs are high, this limited purchasing power limits the number of potential private sector clients and respondents in the 2009 Private Sector Assessment noted that even in Dakar the market was saturated. Even if private healthcare centers are able to obtain the capital necessary to open their doors, without proper healthcare financing and insurance schemes in place, there may not be a market for that they can cater to (SHOPS Assessment, 2009). However, the GOS is committed to expanding healthcare coverage so as coverage expands, the market may expand along with it. Healthcare coverage has expanded since 2009, so it might be worthwhile to see if claims of market saturation still hold true.

List of Studies Referenced: Health Care Utilization in Rural Senegal: The Facts before Extension of Health Insurance to Farmers. International Labor Organization, 2011 http://www.ilo.org/public/english/employment/mifacility/download/repaper2.pdf

Senegal Continuous Demographic and Health Survey 2012 -2013. http://dhsprogram.com/publications/publication-fr288-dhs-final-reports.cfm

Senegal Private Health Sector Rapid Assessment. Private Sector Partnerships for Better Health, 2009. (SHOPS Assessment) http://www.shopsproject.org/sites/default/files/resources/5272_file_FINAL_Senegal_Assessment_rev.pdf

Universal Health Coverage Measurement in a Lower-Middle Income Country: A Senegalese Case Study. Abt Associates, 2014. https://www.hfgproject.org/wp-content/uploads/2014/04/Senegal_Case-Study-on- Measuring-Progress-towards-UHC.pdf

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 20 ANNEX B: FRAMEWORK SPREADSHEET

The model spreadsheet is provided as a separate Excel file which constitutes an integral part of this report.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 21 ANNEX C: PRIVATE SECTOR SURVEY

Rapid Survey on Financial Needs of Private Health Providers

Introduction: please read the following statement to the provider before the interview:

I am here on behalf of the USAID funded financing Growth project. We are working in partnership with USAID Senegal and other local stakeholders to investigate the demand and need for finance among private healthcare businesses. Your answer will help us identify areas of technical support that our project can provide to help improve your business. The interview will take about 20-30 minutes to complete. We appreciate your cooperation and thank you for your time.

Date of interview:

Name of business:

Date of establishment:

Address:

Location of operations (including branches):

Business Owner(s)/Manager:

Contact phone number:

Name & position of respondent:

GENERAL QUESTIONS

1. What type of health care business do you operate?

2. If you are health service provider, what type of services does your facility offer?  General medical services  Pharmacy  Specialized medical services,  X-ray, U/S and other diagnostic services Specify______ Other______ Laboratory

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 22 3. How many patients or clients do you serve in a typical day/year? Specify ______Notes:

4. What is the ownership structure of your business (company/sole proprietorship)?  Sole-proprietorship  Other______ Limited liability company

5. How many employees does your business engage currently (please specify fulltime and part-time employees separately)? Total Employees______

Employee type Total # # Full-time # Part-time

Specialized doctors

General practitioners

Other health professionals

Administration and finance

Do you have problems in acquiring qualified staff?  Yes  No

Notes:

6. What the average (daily), (monthly), (yearly) revenue? Amount: ______(daily) ______(monthly) ______(yearly)

Does it fluctuate during the year?  Yes  No  If yes, what it is the highest / lowest amount per month? o Highest ______o Lowest ______Notes:

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 23 7. What are sources of revenue in your facility / business?

Revenue Source Percentage of Total Revenue Comments

Out-of-pocket expenses

Government Insurance

Private Insurance

Employer Health Program (IPM)

Notes:

8. How did you finance your facility at startup?  Investment of own savings  Family & friends  Bank loan  Other______ Share contribution

Notes:

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 24 9. Do you currently have external financing, please indicate

Lender Amount Total Duration Interest Rate Purpose

Notes:

Did you borrow in the past?  Yes  No  If yes, from which financial institution? o ______o ______10. Do have a banking relationship (bank account, etc.)?  Yes  No  If yes, with which financial institution? o ______o ______Notes: 11. Does your business have positive cash flow?  Yes  No  Do not know

Notes:

12. Is your business profitable?  Yes  No  Do not know

Notes:

13. What are you key challenges in operating a private business? Name three (3) top challenges.

 ______ ______ ______

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 25 Notes:

FINANCING NEEDS

1. Do you have plans for expanding or upgrading your business?  Yes  No  Not sure

Notes:

2. If yes, in what service areas?  Specialized Medical Services  Inpatient services  Modern medical equipment diagnostic  Other ______services  Other:______ Pharmacies / drug store  Outpatient services

Notes:

3. Are you interested in taking a loan to finance expansion?  Yes (if checked, continue to Q11)  Don’t know/Not sure (if checked, go to  No (if checked, go to Q15#) Q15#)

4. If yes, how much would you be able to repay if you could borrow?  <1,000,000  25,000,000 – 100,000,000  1,000,000 – 5,000,000  >100,000,000  5,000,000 – 25,000,000  Other amount ______

Notes:

5. Toward what purpose would you use the loan?  Upgrading/expanding existing premises  Line of credit/Overdraft  Buying new medical equipment  Other  Working capital

Notes:

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 26 6. What type of financing would you be interested in?

 Enterprise loan  Leasing  Equipment loan  Factoring / Invoice discounting  Working capital loan  Other  Line of credit/Overdraft  Mortgage loan

7. What is the shortest period of time that you would be able to pay back the loan?  Up to 1 year  1 – 3 years  3 – 5 years  more than 5 year

8. Will you be able to offer collateral for the loan?  Yes  No

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 27 9. Will you be able to offer collateral for the loan?  Yes  No

10. If yes, what is the collateral? Check all that apply.  Land  Building  Equipment  Personal property (residence, vehicle, etc.)  Other______

11. If you don’t get a loan, how do you plan to finance the expansion?  Use own/saving investment  Get share contributions  Borrow from friends & family  Postpone expansion into future  Other______

ADDITIONAL COMMENTS

1. Is there anything else that you would like to share to help us design a better program?

Thank you very much for your time and your inputs. After we finish the interviews, we will share the summary of our findings with you.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 28 ANNEX D: LIST OF PRIVATE HEALTH FACILITIES INTERVIEWED

Name Facility Contact Mamadou Diouf Clinique Diambar 77 268 6350 Major Ibrahima Beauger Cabinet SABES 77 6511071 Dr Venn Cabinet Dr Venn 33 9611196 Dr Aminata Traore Cabinet Bakline 33 9789595 Dr Mbaye Thiam Pharmacie Mouhamadou Fadel 33 9767676 Dr Fara Wade Clinique El hadj Adama Wade 33 9618866 Mamour Sene Clinique Mouhamadou Fadel Assa Diarra Clinique du Magal 77 253 1316 Frere Brice Hopital Saint Jean de Dieu Dr Sire Niane Cabinet d’ophtalmologie 339514622 Dr Tidiane Siby Bio24 77 6373951 Dr Tene Diop AMH 33 8258592 Dr Abdoul A Kasse Clinique des mamelles 33 8691318 Dr Manuel Pina Cabinet Dr Pina 33 8229431 Baidy Barro Maison du medecin 77 4504095 Dr Cheikh Sidy Beye Pharmacie des allees 33 8252368 Dr Mahmoud Aidibe Clinique de la Medeleine 33 8899438 Dr Abib Saad Clinique La sagesse 33 9514545 Dr Dia Clinique Foulo 33 951 4744 Ibra sow Cabinet Santé pour tous 77 783 8371 Dr Badiane Pharmacie Xandar 77 532 1568 Gorgui Pouye Cardio Medical 77 6381552 Dr Bachir Dieng Cabinet Dentaire Bassirou Mbacke 55 5418967 Dr Babacar Gueye Intrahealth 33 8699474 Dr Cheikh Sarr ADEMAS 77 5578911 Sanou Gning MSI 77 5534500 Mame marie Fall MSI 77 2964789 Elhadi Cisse Pfizer 77 6399781

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 29 ANNEX E: PROFILES OF KEY PRIVATE HEALTHCARE FACILITIES

PROVIDER PROFILE I

PROVIDER TYPE: Hospitals

OWNERSHIP: Private none profit owned by the church

SERVICES: All services are provided

CLIENTS: Between 15,000 and 30,000 annually

TARGET MARKET: Poor people

STAFFING: Have medical doctors, nurses and midwives. Do not have problem in acquiring new staff

LOCATION: In urban areas, especially in Thies REVENUE STRUCTURE: Most of the revenues are out-of-pocket and mutual health organizations and IPM

FINANCING NEEDS: From 150,000,000 to CFA 300,000,000 CFA ($300,000 - $600,000) KEY RISKS / CHALLENGES: Very risky because none profit hospital and social prices applied.

Because of their private status, cannot be included to the Universal Health Coverage and the ideology of the church is a barrier to access to bank loan

SUMMARY

PROVIDERS

They are owned by the churches and are socially oriented hospital where poor people can get access to affordable health services. Some of them are willing to borrow whilst other churches are opposed. They are concerned about the high interest rate from traditional banks.

MARKET OUTLOOK:

There is market potential for hospital services. There are only 4 private hospitals in the country. A fifth one is under construction and will open soon.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 30 PROVIDER PROFILE II

PROVIDER TYPE: Clinics

OWNERSHIP: Most are a limited liability company

SERVICES: All of them deliver general medicine services with a predominance of gynecology

CLIENTS: From 5,000 to 20,000 per year

TARGET MARKET: People with fair purchasing power

STAFFING: Medical doctors (generalist and specialist), nurses, midwives

LOCATION: All located in urban cities REVENUE STRUCTURE: Most of the revenues collected are out-of-pocket (75-90%), and the rest is private health insurance and IPM

FINANCING NEEDS: From 7,000,000 CFA to 150,000,000 CFA ($14,000 - $300,000) KEY RISKS / CHALLENGES: The majority of them are low risk because the business is profitable; they are organized as a Limited Liability Company and have built a bank relationship. However, they suffer from cash money due to arrangements with private insurance companies and late payment. Another challenge is they cannot always provide the required collaterals to get access to bank loans. The majority of funding needs is for new construction and expansion which increases the risk and requires an extended grace period on loans.

SUMMARY

PROVIDERS: Owners of the clinics have in general a positive outlook on growth and are interested in expanding their facilities. The willingness to borrow is high although the providers may be constrained by their ability to provide collateral. The majority of funding would be requested for construction and expansion of facilities followed by equipment.

MARKET OUTLOOK: There are still a lot of opportunities in urban areas where the demand for health care from the private sector is strong and exceeds the supply. With the trend of economic growth and the population growth, the demand will continue to grow. A part of Dakar city center, the private sector is expected to grow in the next 10 years at least.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 31 PROVIDER PROFILE III

PROVIDER TYPE: Cabinets

OWNERSHIP Predominantly sole proprietorships

SERVICES: Most of them are generalist even though some specialists operate on their own like gynecologist, ophthalmologist, dentist, radiologist and pediatrics.

CLIENTS: Range from 700 to 2,500 in paramedic clinics and 1,500-5,000 in medical cabinets a year

TARGET MARKET: Middle class patients with a purchasing power, fees charges range from 2,000 CFA for paramedic cabinets and 5,000 CFA for doctors outside Dakar to 25,000 – 35,000 CFA in Dakar

STAFFING: One doctor or paramedic assisted by nurses

LOCATION: Urban areas where people have a fair purchasing power

REVENUE STRUCTURE: Mainly from out of pocket and private insurance

FINANCING NEEDS: Need financial support to grow their business. This range from 20,000,000 to 80,000,000 KEY RISKS / CHALLENGES: Risky because sole owned and the age of the owner (paramedic clinics)

SUMMARY

PROVIDERS

In paramedic cabinets, the owners are quite old. They are retired whilst in the medical cabinets they may be younger. A big concern is the likelihood for replacement to whose existing now, lack of succession plans.

MARKET OUTLOOK:

Opportunities are available for the market to grow even enough the demand is very low at the current prices for services. The rural areas lack providers mostly because of lack of revenue. The market is still available however in some areas like Dakar city center; there are no opportunities for new entrants, only in new neighborhoods.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 32 ANNEX F: HEALTH LENDING OPPORTUNITIES IN SENEGAL: SUMMARY OF THE PROJECTIONS

TOTAL POTENTIAL DEMAND FOR FINANCING BY TYPE AND SEGMENT

Baseline Year 2 Year 3 Year 4 Year 5 Total Year

TOTAL BY TYPE OF FINANCIAL NEEDS Working Capital 832,163 908,210 991,986 1,082,711 1,182,028 4,997,097 Equipment 2,862,438 3,116,973 3,414,566 3,735,337 4,073,523 17,202,837 Facility Expansion 7,304,863 8,430,085 9,218,283 10,192,059 11,028,759 46,174,049

TOTAL BY MARKET SEGMENT

Health Services Delivery Market 9,590,263 10,904,628 11,952,912 13,210,836 14,322,417 59,981,055 Pharmaceutical Value Chain 941,200 1,062,620 1,163,333 1,269,545 1,410,449 5,847,146 Equipment and Medical Supplies Value Chain 468,000 488,020 508,591 529,727 551,444 2,545,782 Health Education Market ------TOTAL 10,999,463 12,455,268 13,624,835 15,010,107 16,284,310 68,373,983

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 33 Lending Opportunities in the Private Health Sector

16,284,310 15,010,107 13,624,835 12,455,268 10,999,463

Baseline Year Year 2 Year 3 Year 4 Year 5

Lending Opportunities in the Health Sector by Type of Financing Needs 12,000,000

10,000,000

8,000,000

6,000,000

4,000,000

2,000,000

- Baseline Year Year 2 Year 3 Year 4 Year 5

Working Capital Equipment Facility Expansion

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 34 Average Loan Amount by Type of Financial Needs 40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

- Baseline Year Year 2 Year 3 Year 4 Year 5

Working Capital Equipment Facility Expansion

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 35 Average Loan Amount by Market Segment 100,000

90,000

80,000

70,000

60,000

50,000

40,000

30,000

20,000

10,000

- Baseline Year Year 2 Year 3 Year 4 Year 5

Health Services Delivery Market Pharmaceutical Value Chain Equipment and Medical Supplies Value Chain

For details of the calculations and estimates, see the model attached to this report as an Excel spreadsheet.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 36 ANNEX G: MODEL CALCULATIONS FOR SENEGAL

The model spreadsheet is provided as a separate Excel file which constitutes an integral part of this report.

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 37 ANNEX H: LIST OF FINANCIAL INSTITUTIONS INTERESTED IN HEALTH LENDING

Senegal Bank contact list Germaine DIENE SOKHNA Head Local Corporate Ecobank Tel: 00 221 77 637 53 62 / 00 221 33 849 20 13 Email: [email protected] El Aly SOW Directeur des financements speciaux et club des investisseurs CBAO Tel : +221 33 849 96 96/+221 77 332 6723 Email : [email protected]/[email protected] Mor Niass Directeur CBAO Direction Marche Pro/TPE/Autres institutionnels Tel : +221 77 637 13 30 Email : [email protected] Laurent Basque Directeur General Bank of Africa Tel : +221 33 865 6464 Email : [email protected] Mouhamadou Ndiaye Directeur BICIS Direction des Etudes et des Relations Extérieures Tel : +221 33 839 0414/33 839 0441 Email : [email protected] Alexandra Awadi Chef de Service Banque Atlantique Grandes Entrepris des et Financements structures Tel; +221 33 849 9282 Email: [email protected] Papa Aly Ndior Directeur General Adjoint ACEP (MFI) Tel : +221 33 869 7550 Mail : [email protected]

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 38 ANNEX I: EXIT DEBRIEFING WITH USAID SENEGAL

Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 39 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 40 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 41 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 42 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 43 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 44 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 45 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 46 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 47 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 48 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 49 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 50 Work Order 2014 – 03: Assessment of Healthcare Related Investment and Financing Opportunities in Senegal 51