Global Perspectives on Digital Health

Rowena (00:00)
In terms of where we are right now with global health, it's a scary time. And to be frank, having worked in this space for the past 20 years, I know dozens of organizations, thousand person organizations that have basically disappeared in the course of a week or two. The industry is in turmoil.

And at a macro scale, as you mentioned, USAID has cut 80 % of its programs, the WHO is downsizing by 20%, And so it is a true moment of, one might say crisis, one might say transformation for the global health community.

So there is a question of what's gonna happen with aid and how that evolves with all this. But Africa isn't going anywhere. There's lots of different ways in which people work with, people support Africa, And many of those flows of capital, many of those businesses and industries and workforces are larger than the aid industry. And that's something to keep in mind, particularly for those that

Maybe were in the aid industry and are thinking, okay, what is the next step? What makes sense here? What are we gonna do in a future which is inevitably going to be leaner, inevitably is gonna have less philanthropic dollars? How can we make a dollar go further in the current world

And if you're in Africa like I am, and you're investing, it's not impact investing, it's just investing. It's just recognizing that there's gonna be half a billion people born here in the next 10 years. And those people are gonna need healthcare. Healthcare is a defensive market. Whatever's happening with global macroeconomic scale, those people are gonna need medicines, they're gonna be delivering babies. And that is an undeniable market growth for which there's an opportunity, not just to meet the need of the moment, but to create

Shubhanan Upadhyay (01:21)
Mm-hmm.

Rowena (01:42)
efficient, scalable innovations that will deliver healthcare effectively to that population. And so the moment I really believe is now, given how much growth is happening right now in Africa and what that trajectory looks like over the course of the next 30 years.

Shubhanan Upadhyay (02:04)
Rowena, it's so, so great to have you on the Global Perspectives on Digital Health podcast. Thank you for taking the time to join us. I'm really, really excited to be able to talk to you about this particular topic. right now, given everything that's going on, but please tell us about you. I consider you as one of the OGs of bringing visibility to what's going on in terms of digital health in Africa.

And so I'd love for you to share a little bit about your journey and the work that you're doing with Africa Health Ventures.

Rowena (02:35)
Shubs, it's a pleasure to be here today. Thank you so much for hosting me. And I also want to give a shout out to you for carrying forward the torch on a global health podcast. There aren't enough global health podcasts. I know I did one earlier, which has now shifted over to the African Adventures podcast. And I love what you're doing to carry forward the space and this information. First, let me introduce a little bit about myself. So my name is Rowena Luk. I'm based in South Africa. I've been here about 10 years and then working on the continent for the past 20.

I'm originally a software engineer by training. So sometimes the geek gets out of me. I'm originally from Canada,

Shubhanan Upadhyay (03:10)
Mm-hmm.

Rowena (03:13)
Yeah, so over the course of the past 20 years, I've built two social enterprises and two nonprofits all squarely focused on healthcare innovations in Africa. Those were phenomenal experiences. They gave me the opportunity to build national scale health implementations. For example, I built the software diagnostic, which today is used in every primary care facility in Burkina Faso, the supply chain tool used to distribute family planning commodities across Senegal.

supported the tool that was used to manage outbreak monitoring across Uganda and various other examples like that in Ethiopia, Malawi and elsewhere. And that was really an opportunity for me to cut my teeth in terms of what does it take to build a business, build a nonprofit, build products that work and that scale in African healthcare markets. Then a few years ago, I would say my personal existential crisis happened in 2020.

as I know it did for many people listening to this podcast. Not only was I struck by the COVID-19 epidemic and everything that that changed about the hard lockdown we experienced here in South Africa, but I was also burnt out from years of entrepreneurship. was pregnant with my second child and took the opportunity to shift into a different space. That's when I realized what I was really passionate about is investing in entrepreneurs, in young people.

in those that see a future that's better than what we have right now. And that's when I transitioned over into impact investing. So over from there, moved from angel investor to building a venture philanthropy vehicle in Canada. And then finally over to Africa Health Ventures, where today I'm managing partner investing in seed stage healthcare innovations that will dramatically improve access and quality of healthcare in Africa and around the world.

Shubhanan Upadhyay (05:03)
Awesome. What a journey. actually, I mean, I don't know how common this is, but having someone who's actually implemented and being a software engineer in terms of background to then going into investment, I feel that that must be great for the rapport that you build with the people who are then on the ground and knowing what they're going through,

maybe people might perceive like investors kind of being in the clouds a bit, but actually you've been there and like been on the ground. so that must help.

Rowena (05:29)
Yeah,

just to add to that, I hope it is one of the biggest differentiators that we bring to our portfolio. I recognize now more than ever that a lot of investors are finance professionals or other kinds of professionals, but it's very different talking to someone who actually understands the business. And I see the work that we're doing as not just finding a strong investment opportunity that already exists and pouring capital into it, but creating those opportunities, guiding entrepreneurs into the spaces where

We believe there's a massive market and opportunity and not enough innovation and then helping them in those first pivotal steps where capital can be truly catalytic and where our intervention can be truly catalytic in shaping their long-term trajectory.

Shubhanan Upadhyay (06:09)
Yeah, I mean, this is a good segue for me in many people's experience, thinking about digital health or healthcare or improving healthcare within Sub-Saharan Africa, within parts of Asia, I think people might have the assumption or easily go to the assumption that the only way for this to occur or to be funded is through kind of government aid.

or philanthropic foundations, et cetera. But if you can give us an idea of like, I guess like the background of how like impact investing has kind of built up.

And I'd love to understand what was going on kind of before government aid has kind of suddenly like geopolitically completely shifted, for example, with USAID cuts, not just USAID, there's other governments have also done that, UK government has done that as well. And so I think a lot of people have like now noticed more.

actually, it's not just philanthropic foundations who are maybe having to step in, but this whole infrastructure of investment in Africa. So if you could give us your overview of how that's evolved and where things are at.

Rowena (07:14)
Yeah, absolutely. So much to say on this topic. One, in terms of where we are right now with global health, it's a scary time. And to be frank, having worked in this space for the past 20 years, I know dozens of organizations, thousand person organizations that have basically disappeared in the course of a week or two. The industry is in turmoil. And that means that a lot of close colleagues, a lot of business partners, a lot of people that used to be my clients are gone.

Shubhanan Upadhyay (07:17)
Mm-hmm.

Rowena (07:42)
And at a macro scale, as you mentioned, USAID has cut 80 % of its programs, the WHO is downsizing by 20%, and there's a lot of open questions from the Global Fund and the UN agencies with the withdrawal of not just American money, but European money and everywhere else in the world. And so it is a true moment of, one might say crisis, one might say transformation for the global health community.

And there's a lot to be thoughtful and intentional about in how we shape the opportunity that presents itself now in this year, particularly for those of us that are passionate about healthcare, about bringing better healthcare to Africa. I'd like to put that whole industry that, as some call the aid industrial complex, within a broader context. So in 2023, the US government put about $10 billion into health and humanitarian assistance in Africa.

And then if you compare that number to foreign direct, actually let's start with remittances. Remittances into Africa, again I'm not speaking about healthcare at all, that's $50 billion as an industry. If you look at foreign direct investments, that's $70 billion. If you look at trade, that's hundreds of billions of dollars all pouring into Africa, all being used to create jobs, create wealth, and through those processes ultimately fund other programs. So there is a question of what's gonna happen with

aid and how that evolves with all this. But Africa isn't going anywhere. There's lots of different ways in which people work with, people support Africa, in which diaspora to give back money, in which businesses are built, in which governments fund health programs. And many of those flows of capital, many of those businesses and industries and workforces are larger than the aid industry. And that's something to keep in mind, particularly for those that

Maybe were in the aid industry and are thinking, okay, what is the next step? What makes sense here? What are we gonna do in a future which is inevitably going to be leaner, inevitably is gonna have less philanthropic dollars? How can we make a dollar go further in the current world than it could have gone last year or even 10 years ago? The other aspect that I'll add is, just in response to your comment, you're talking about how there's a sense that healthcare in Africa has to be a philanthropic project.

I find to my own surprise, particularly given I have such a strong history of working with American colleagues, that that sentiment is particularly strong in the United States. When you talk to investors, impact investors and regular investors in Europe, in Asia, in Africa, it's much more normalized. There's much more understanding of what's going on in the economies, the opportunity that exists in these economies.

And if you're in Africa like I am, and you're investing, it's not impact investing, it's just investing. It's just recognizing that there's gonna be half a billion people born here in the next 10 years. And those people are gonna need healthcare. Healthcare is a defensive market. Whatever's happening with global macroeconomic scale, those people are gonna need medicines, they're gonna be delivering babies. And that is an undeniable market growth for which there's an opportunity, not just to meet the need of the moment, but to create

Shubhanan Upadhyay (10:29)
Mm-hmm.

Rowena (10:51)
efficient, scalable innovations that will deliver healthcare effectively to that population. And so the moment I really believe is now, particularly given what's going on in the global health world, particularly given how much growth is happening right now in Africa and what that trajectory looks like over the course of the next 30 years.

We have the opportunity to create those businesses on these continents and investing, I find, as a particularly valuable vehicle to do that,

for many different reasons. Maybe one key reason I'll pull out why investment is such an tool, such an important approach to the healthcare space is that if you're working on the research side, ultimately the product of a lot of research is the science itself, which can be published in a paper. So you do the study, you publish the paper, you're done. And you've achieved your goals as a researcher. If you're working on a philanthropic project, most of those projects, let's say USAID projects, for example,

It's a five year program, know, do a certain amount of work, transfer it to government, and then you're done in five years. When we talk about investing in organizations of any kind, we're talking about investing in the core operations of an organization with a goal of having it scale and survive and thrive. Investing allows organizations to build the core bones and skeletons

that they need in order to have scalable, resilient enterprises. There's many reasons. Let's look at a private healthcare or health tech company, for example. It's hard to find research funding or donor funding that's going to pay for a human resources person or a business development person or to file your taxes and certain things like that. Whereas with investing, particularly impact investing, you're investing in the core opportunity of the organization itself.

And then when the market that the organization serves is hit with these massive shocks, like what we're seeing right now with USAID, then that organization can evolve. They can move rapidly, like we're seeing right now. Where it used to be that, yes, there was a stream of funding and work that came from nonprofits. There's a stream of funding of work that came from global donors. But regardless of what happens with those, people still need medicines. They still need healthcare. And so if it's not coming from that space, then those businesses will evolve.

and work with governments, with charities, with local charities, with out-of-pocket spending in order to survive, in order to continue doing the work that we're doing.

Shubhanan Upadhyay (13:19)
Such a great overview on the case and the kind of some of the nuances of considerations of what investing can add. Some skeptics might say, well, if you look at like the so-called like global north or western model of VC funding, thinking about growth at all costs.

and the ROI that you'd get as an investor. People might have looked towards philanthropy or even aid in some ways, there could be also a perception that, well, they're looking at the long game. They're looking at the societal benefits as an ROI.

and the bigger value. And there might just be this assumption that, well, investment vehicles will be mainly focusing on like the financial returns that they would be getting. And that would be the key kind of pressure on an organization that you've invested in. What would you say to that?

Rowena (14:09)
so much to say on this topic. First, respond to the first point that you're making. Philanthropy is about the long game. In theory, that should be the case. In theory, when you look at, you know, a billion dollar programs and all the metrics and the indicators and the thinking that has gone into it, that should be the case. In practice, it's not. In practice, just like every politician runs on a four year cycle and those programs are funded by politicians. In practice, because these programs are funded

For five years, in the best case, often for one years or two years, and then they're looking to make that story to do their fundraising, the reality that anyone in global health sector will reiterate is that the thinking for a lot of project, program, and research funding is short-term, even though there are many individuals and many leaders in those organizations that would hope for a longer-term approach. I would argue that, I mean, one, just on philanthropy in general,

Absolutely essential. Nothing that I do is meaning to imply that we don't need research, we don't need philanthropy. There will always be a tier particularly when we're talking about conflict zones, particularly when we're talking about the poorest of the poor, where government services and out of pocket philanthropy is gonna be necessary. And when I see examples of that working successfully and efficiently, I love it. And I would love to see more people rise to that opportunity. But going back to investing and the approach that investors take,

I would argue that investors like myself have a certain onus to look even longer term than most of the programs that we've seen, particularly comparing them to the global health space. So if you look at Africa Health Ventures, for example, we're a 10 year close ended fund with the option to renew for one or two years. And what that means is we find businesses, innovative businesses that are in their earliest stages and we go with them throughout that journey. We're taking an idea, know, some initial signs of traction.

And we're bringing it not just to national scale in one country, but national scale in multiple African countries or international scale. And that's our success. And that's what we're accountable for in terms of what we're delivering. And so we need to take at least a 10 year perspective, if not longer, when you look over the course of multiple fund lives. The other aspect that I'll say is that all of us are hoping to build sustainable organizations and all of us are hoping to scale.

you whether you're scaling impact or you're scaling your scaling financials, what you need is an organization that is financially sound, you know, that is contributing something of value to the markets that they serve. And while we might not be able to serve the very poorest of the poor, the very bottom of the pyramid, there are many, many tiers, one step up or two step up, the entire population of blue collar workers, where there is some willingness to pay, there's some ability to pay.

And we're seeing that healthcare is one of the top priorities that people can pay for as they emerge out of poverty and that creates a positive cycle towards greater economic empowerment. So to the extent that we can invest in that virtuous cycle, to the extent that we can create markets that not only catalyze healthcare, but catalyze the rails for a much broader population to live healthy lives and to embrace their own wellness. I think that's something that's worth fighting for.

Shubhanan Upadhyay (17:25)
Yeah, that sounds really great. And yeah, I really like the scaling, the impact that you said. And yeah, really, convincing and impassioned argument for thinking about this this way. I think also, when you're thinking about philanthropy you mentioned programs that get funded. Often these are top down.

Concentrate on X. Let's try and get this technology into this region, right? And as part of what you're saying, I think another link that I make is actually what this if you're supporting the organization to kind of build out and create the impact that actually matters in that context, you're kind of allowing a more bottom-up approach in some ways. And so you haven't got like a specific.

to be put very cynically, like a specific agenda in terms of a specific program, like, we need to solve disease X when actually in reality, disease X doesn't exist in its own little silo and there's so many more confounding factors around that that contribute to that. So I guess, yeah, it's an argument for like building up from the ground, right?

Rowena (18:24)
Yes, yes, mean that just,

no absolutely and that really strikes a chord for me and I'm sure for you as well in that a lot of global health funding is very verticalized, it's very programs driven. But if you're an entrepreneur on the ground and your goal is to increase, create value for health insurance, if your goal is to roll out universal health care, it's not about whether it's HIV or malaria or diabetes. Ultimately it's just about how do we deliver medicines.

to people, how do we teach people to take control of their own health? And from the perspective of a person in the community or a client, or an emerging client in an emerging market, it's all one in the same. And then that allows for certain greater focus on the health system rather than these very specific, sometimes program specific indicators. The other thing that I'll build on top of what you're saying in terms of how the accountability of these systems work is for

As for donor-based funding, for a lot of global health, you know, donor funding, the accountability ultimately flows up to the funder. be they a government, be they a family foundation, or be they someone else. And that person or that team sitting in Washington, D.C., or Seattle could be so many time zones and cultures and realities removed from the program that's being implemented on the ground. could be a world away.

I will acknowledge one critique of looking at private sector investments is that we do work, is that when we try to build sustainable business models, when we invest, we make sure that we're targeting at least the bottom one, two, three quintiles of the population from an economic perspective. And acknowledge that there are times where we are also leveraging what we can get from the middle income and for upper income populations. But I will say ultimately,

in terms of building resilient localized systems, in terms of fostering African entrepreneurship, in terms of creating an accountability to a Kenyan in Kenya who can use the system, regardless of whether they're high, middle or low income. We don't see enough of that. We see too many systems that are accountable to some donor somewhere in the world who wants a pretty story that can be published in a newsletter. And we're not seeing enough solutions that can meet the needs of the whole

market and can adapt quickly because the accountability sits within that market, particularly as that market is growing and it's expanding.

Shubhanan Upadhyay (20:47)
Yeah, absolutely. And you talked about this being kind of like a watershed moment. And just to give a big shout out to your part of your work with Africa ventures is you run, you run this newsletter and you've, you've written some very insightful posts. You've also done a kind of a podcast interview episode of kind of what's been going on in the chaos that's ensued. So definitely have a read of that. I'll link it in the, in the show notes. It's very, very helpful and useful. And.

I mean, so I'm a medic by background. I'm a family physician. And when I observe what's going on, I kind of make the analogy, you consider global health as the subject and as a patient, this patient is currently in the intensive care unit. There has been a lot of triage been going on. Some vital organs have been lost and everyone's thinking about survival. How do you save critical infrastructure?

the critical things have been lost. And so part of it is triaging what can we salvage? How can we then stabilize and maintain what we can and what has existed? And then the third part of conversation when someone's in an intensive care unit from medical perspective is, all right, now we've stabilized this patient. What do we need to do as we step down the level of acuity of care?

How do we stop this person coming back into ICU in the future? What preventative measures do we need? And so if I think about what's going on with global health at the moment, that conversation around now this being the most watershed moment of like, do we get here? Like why was there with this almost a single point of failure, Like collectively, all the decisions that have been made to get us here, how do we like think about, know, Nicholas Nassim Taleb talks about being antifragile.

right? How do we build back more resilient? And so if we now think about, we've talked a little bit about the past, we've talked a little bit about where we are, how does this global health patient of ours in ICU, in intensive care unit, how do we think about addressing those risk factors that got it, get this patient here in the first place?

Rowena (22:48)
Wow, talk about easy questions. No problem, I got it. But in all seriousness, I mean, there's so many facets to that question and so much we can learn from the opportunity that's presenting itself. And even those that were existing and thriving within the old world order would recognize that there was a lot that needed to change, a lot of inefficiencies in the system, a lack of...

ownership and a lack of leadership within the countries that we aim to serve, as well as significant political interests from the donors that they were trying to express through aid. And so what we can see from this moment in terms of how to create more resilience, more accountable healthcare systems, one is recognizing that it's going to be a leaner future than it is in the past.

looking at how to remove all the layers of inefficiency that prevent us from working with local organizations. And so that's something that is particularly important for a private business, but it's also extremely important for nonprofits as well, which is that accountability to local communities, that accountability to local markets. I what does it mean that to be able to take the capital that is available, take the resources that are available and

put them closer to the communities so that they can have greater accountability and reduce the inefficiencies of flying in international United Nations personnel at $500 per day per diem and various things like that. So that's one aspect of it. I think the other aspect that I would look to is the particularly, the ways in which we can make our capital go farther. And so there's certain things that large institutions

can back, if you're working with government money, if you're working with taxpayer money, you're gonna be investing in government run programs, you're gonna be investing in growth scale businesses. If you are a family foundation, if you're a smaller actor, if you're someone who can take more risks, then there is a critical space for you that is not filled by others. And a lot of times when I think of impact investing, like what is impact investing?

Maybe I would say impact investing is the ability to accept greater risk for greater returns. Like looking at a business which is building life changing diagnostics in a corner of Africa and recognizing, hey, you know, it's a corner of Africa. You're not doing this in Geneva. It's, you you don't have the resources and it would be easier to invest in the same organization in Geneva. But if it succeeds, if it can succeed here, if it can serve the whole continent closer, locally manufactured,

you know, local distribution channels, then the opportunity for impact is outsized because of that. And so would say to the extent that different people listening to this podcast might be thinking, you know, how do I make my splash in the world? I think there's this aspect of recognizing what is the unique contribution that we can all make, be it with our time or be it with our capital, in order to improve the way that we're thinking about innovation, thinking about organizations and thinking about systems change.

Shubhanan Upadhyay (26:00)
And so it sounds like also you, with impact investment or people who think like you, you're thinking about impact or the creation of value with a wide lens. In terms of the impact that you can have in a corner of Africa that is, I guess it links to what I saying earlier, which is traditional VC thinking is like thinking about

the value that's created or the return as being financial only. I guess why interpret or read between the lines of what you're saying is that actually maybe one of the unique differences with impact investing is you see the bigger picture and yes, there's a financial aspect, but there are other aspects that are what you're measuring as success. Would you see it the same way?

Rowena (26:45)
I guess what nuance I would add to that is that there are as many flavors of impact investors, impact funds, as there are businesses and donors and everything else. And depending on which impact funds you talk to, there are some funds that will claim to be an impact fund because they work in Africa at all, even though they're working on purely commercial cutthroat terms. And so it's a pretty wide spectrum. I will say a lot of impact funds in Africa focus primarily

alongside financial returns in employments, in skills training, in economic output, in productivity and measure in those terms. Where we're unique is we're actually looking at health outcomes. How do we actually improve access? How do we improve cost or lower the cost of healthcare so that more people can gain access to it? How do we improve the quality of healthcare that's delivered? And that's something that we are uniquely positioned to do as a healthcare fund. In the private sector, there aren't.

that many healthcare funds, particularly in Africa, most funds tend to be sector agnostic. But for us working in this space, it's hard to imagine creating the kind of value that we can create without being sector specific. And it's hard to imagine it being possible to measure impact the way that we measure impact, unless you're taking a sector specific approach. And that's part of the contribution that we're making towards the ecosystem. The other aspect that I'll say as well is that

is that yes, we are looking for financial returns. We are looking to return profit to our investors over the course of the investment period. We see that as a natural product of seeking out businesses that are meeting a market opportunity. And then there's various, and there's very different kinds of markets. Again, as I mentioned, we're looking at the bottom one, two, three quintiles of the market. And we believe if we're successful in identifying those opportunities, if we're successful in meeting the need where it is,

then the market will respond to that. And that's why we're able to return. And last but not least, the model that we've chosen is because we're looking for market creating innovations. We're looking for the kind of innovations that will not just be deployed in one district or in one county, but will have the potential to scale massively because we want that catalytic effect. And that trajectory of scale

That scope of what we're hoping for is another reason why we're able to model out the financial returns that we can in the fund.

Shubhanan Upadhyay (29:08)
Great. That's a really nice segue actually into the next section, You talked about being sector specific already from a healthcare perspective and the things that you need to concentrate on. The other thing is in terms of investing in continent of Africa.

what are the main key nuances of investing in Africa

Rowena (29:31)
Yeah, let me talk a little bit first about the market opportunity of Africa because before I switched into the impact investing space, we really didn't talk about it that much. And it's important to understand that market opportunity in order to be investing in this space. So Africa is home to 11%, 11 % of the world's population. It houses 25 % of the global disease burden and yet captures only 4 % of the global pharmaceutical market.

So there's a massive opportunity there that's just waiting to grow. The other aspect of it, which we don't talk about enough, is it's the birthplace of humanity. There's more genetic diversity between two people in Africa than anywhere else in the world. And that actually matters if you're doing biological research. If we look at the way in which this continent is structured today and the way in which it's headed, we know by 2050 that one in four people will be in Africa, on the planet. And that's very different than the often saturated

aging populations that we're seeing in the United States and in Europe. While a lot of other economies will plateau, a lot of these other economies are already quite dense in terms of what's going on, in terms of how much technology they have the capacity to absorb. Africa is a much cleaner slate. And in Africa, you have the opportunity to take even innovations that have been demonstrated elsewhere and scale them on this continent.

The average age on the continent is 19 years old, which means we have a young population that has grown up in the era of social media and cell phones and mobile money. And they live on these platforms in a way that I still, I can't even imagine. And what that means in terms of their ability to take up new technologies and innovations to work or to access information, access healthcare information is quite different than...

even what I can imagine, particularly in the era of generative AI that we live in. And then the last piece that I'll say on the market side is there's some really exciting trends for the market. For example, one that we talk about a lot is the Africa Continental Free Trade Agreement, which would do an immense amount to move forward the economic unity of the continent, the same way that we have the economic block of the EU

and North America, if we could capture that kind of market across all of Africa, all of its 54 countries, it's the largest, fastest growing market in the world. In the healthcare context, with the African Medicines Agency creating a unified regulatory body, that means that new medicines, when they come to market, instead of trying to cater to high income markets to buy the more expensive drug or the newest drug or the fanciest designer drug, there's an opportunity to reach

that population that's growing. And again, that's a massive opportunity that any global pharmaceutical company, distributor, insurance company can't ignore. So there's a ton of opportunity and particularly now an opportunity to get ahead of that change that's happening over the course of the next 10, 20, 30 years. The other aspect of it as well, and this is more about the psychology of organizations and of

founders, non-profit or for-profit founders. If you believe you'll always be poor, you'll always be poor. There is this aspect of putting band-aids against what we think is always gonna be Africa's poverty versus creating the opportunity for prosperity. And that's what development is supposed to be about, right? It's supposed to be moving up the ladder. It's supposed to be saying, we're seeing these economies grow. We're seeing people

are getting smarter, they're able to access tools and information in new ways that they never have before. How can we do what we as humans are uniquely capable of? How can we take a step forward like we did with the industrial revolution, with the green revolution, with the internet revolution, with cell phones, with mobile money, with WhatsApp, to leap forward on this continent and actually do something important with our time and our capital at the same time?

I think all of those together make a compelling case for why it is that investors and, in fact, investors have a critical role to play in these markets.

Shubhanan Upadhyay (33:49)
Absolutely, and if you're, as a builder as well, if you're looking to think about, where do I want to have an impact? Finding problems that can really, really affect people in a positive way. And also kind of, basically my summary of what you said is like, this is literally where the ball is going to be very, very soon. And so really thinking about that from a kind of business resilience and sustainability perspective, as well as like working on stuff that matters.

quite inspirational for people who are building as well. Like the previous version, the software engineering version of you, Rowena will be smiling at that. That's so helpful to think about that. you've also kind of, you've done this piece as well on the myths and the realities of investing in Africa. Have you got any key takeaways to share from that as well?

I think that would be really helpful because with this big opportunity, guess there are also assumptions people have, some nuance to it, some things you have to think about carefully, etc. Have you got any kind of summaries from that discussion or some quick things you can give us from there?

Rowena (34:53)
Yeah, absolutely, I thank you for the shout out. We did sit down with some of the leading investors on the continent and put them in a room of international investors and had them ask all their hard questions. Why don't you invest in Africa? What are you worried about? What do you think is the opportunity? And it was a fun discussion. I enjoyed it very much. Some of the things that I would say that's unique or maybe misunderstood, particularly by foreign investors coming into Africa, one is

And maybe this is obvious,

Being able to, I think the Lemba Peirre from ATG Samada said it quite well. She said, if you always fish in the same pond, you'll always catch the same fish. The sad reality of the finance industry from which all these funds emerge from is that they're primarily run by white males. And most of the founders, in any geography where there's a lot of equity investment are gonna be white males. And then you come to Africa and it's diverse, it's messy. There's a lot going on from a lot of different people that's

maybe don't operate in exactly the same way that I might have, particularly when I was working in Canada and the United States, but get things done. They're hustling, they're moving, they're creating, they're building, and they understand the markets and they can build relationships in a way that I never could. And I think that's maybe the first thing that I'll bring to the table is come in and look at the quality of the market, look at the quality of the revenue, look at the quality of the product.

and try to keep your, know, check your biases at the door when you're looking at the kind of founders that are worth backing.

The other piece that I'll point to, and these two are maybe a little bit more nuanced, but I thought they were interesting. One is recognizing what happens in an environment like Africa where there is a shortage of infrastructure. So in Silicon Valley, you can invest in a pure software app that everyone downloads onto their app store and they immediately monetize and it's...

what we call asset light, you a little piece of software that scales massively and makes a bunch of money. In Africa, traditional investors still look for very asset light investments, but because there is more that we want to do to build the infrastructure on this continent, the ones that, one, it's hard to find ones that have the revenue and the traction without providing some aspect of

services or support, et cetera. And two, in order to achieve the outcomes that we want, in order to actually reach people and provide healthcare and things like that, you need to have some allowances for the fact that the infrastructure might be a little bit different than elsewhere. So one example I'll give, which to make it little bit more real, are agent networks. So in America, maybe you have a finance app and you can just...

build the app and release it in the Play Store and do some marketing and you're done. Whereas the most successful agent apps or like out there, sorry, the most successful apps adopted by regular human beings often rely on a massive network of agents that are active in markets, in villages, talking to people and in the case, in the global health space, those could be community health workers as well who are actually.

Shubhanan Upadhyay (37:43)
Mm-hmm.

Rowena (37:45)
putting a face to a very new technology or getting people to subscribe and download and sharing healthcare information and then having the software bring it the rest of the way. And so what you see in Africa is more of those hybrid models where you see a balance between software and something else, be it a little bit of services, a little bit of sale, a little bit of drugs, a little bit of diagnostics or something else. And that I see as an inevitable aspect of capturing this new market.

and contributing to building infrastructure that will need to exist in order for healthcare and other aspects of the market to take off. The other thing that I'll throw in there is when, so I studied product design at Berkeley where I did my master's degree and one of the things they taught us was about identifying needs that people don't know they have and really articulating that and building a product and creating demand like you do with the iPhone, for example.

Shubhanan Upadhyay (38:34)
Mm-hmm.

Rowena (38:40)
In Africa, that's not the problem. There's lots of challenges and people know what those challenges are. There's no need to manufacture need because there is need apparent in lots of different ways. And when you look at products and evaluating products, the way that you see that play out is sometimes there's apps that are quite diverse. They have more all-in-one apps or apps that do two or three things. It's not just a telemedicine app. It's a telemedicine mixed with health insurance, mixed with referral.

Shubhanan Upadhyay (38:45)
they are.

Rowena (39:07)
and it's all kind of together. And I think an investor coming from California might say, like, you know, pick your niche and stick to your niche. And I would say there's a lot of gaps in the healthcare market. And if you're meeting the market where it is, you're providing value that is creating demand and demonstrating demand through your client base, then by all means, you know, you don't need to have one small but beautiful thing. You can do many things. And that can be quite powerful.

Shubhanan Upadhyay (39:34)
That's really helpful. And on the evaluation aspects then, where there then are multiple blended types of offerings that are meeting people where they are, like what they need, and as a way to get to people and actually address their everyday issues. I mean, I've talked to a couple of people on the podcast who have co-designed with communities and kind of had many of their assumptions challenged to then have something that

we thought we would need to evaluate kind of bigger mental health and clinical outcomes. When actually we they realized, actually phase one was improving awareness of this condition. So when you're thinking about evaluating it, you just wanted to pick up on what you said on an evaluation, is, yeah, understanding what the needs are right now. And yes, you might have this bigger vision, especially if you're an investor or builder, like, we want these bigger outcomes.

But they're kind of these milestones to get there that are just necessary to meet people where they are, right? So here it was really understanding, breaking down, stigmas, improving access. And that was a measure of success initially. And you have to do that before you can start turning the wheel on the other stuff. So yeah, it just kind of reflects on something you said there about the reality of where people are.

Rowena (40:36)
Yeah.

That makes so much sense. I think what I'll say I think is also relevant in that context is also this aspect of understanding what the need is, but then also acknowledging where the market is ready to meet it. So I think there's a lot of studies that are done that show this kind of training would be useful. This kind of product will improve health outcomes, et cetera, and lots of solutions that are proposed.

Shubhanan Upadhyay (41:00)
Nice.

Rowena (41:09)
But ultimately, at end of the day, Africa is resource poor today, and you need to pick and choose between solutions. And again, that's another thing that is why I'm so active, particularly in these private sector business models. But it's also true in public sector budgets and various other aspects, which is when you have a finite amount of resources to work with, doing some work, whether as a charity with the government or as a business with your market, to understand, okay, recognizing the diversity of needs, what is the level of

solution, what is the level of service that I can offer that you're actually willing to pay for and validating that before you go too deep down a particular track.

Shubhanan Upadhyay (41:48)
This is really, really insightful and I feel like I could talk to you on this particular section for such a long time. I've got, some, more quick fire types of questions.

that will be, I think, helpful for either people who are considering building in this space or investing in this space. One is, and you talk just now as well about picking and choosing the right types of solutions that are serving the most important needs. have you got an example of a startup, either that's in your portfolio or that you see that you've come across that's exciting you, just like really hitting that really well?

Rowena (42:22)
Yeah, absolutely. I'll talk about two. I love the whole portfolio, so it's hard to pick. So in our portfolio, and recall, we're investing in seed stage companies. So early stage, high risk companies that we believe could really change the shape of a market. But they are early and they are young. So one company I'll highlight is a company called Remedy in Egypt. It's a diagnostics company. found by Dr. Salma Tamam. She's in Africa.

Shubhanan Upadhyay (42:32)
Mm-hmm.

Rowena (42:47)
She is a woman, she's a first-time founder, she's solo. For many different reasons, you would think she's never gonna get funded and that this might have to be a charity case of some kind. Then you look at the other side of the equation, she's brilliant. She has 40 peer-reviewed published papers. She was the one that the government of Egypt called on to build COVID-19 diagnostics when they weren't available in Africa because the rest of the world was hoarding them. And then when the government of Egypt pulled back,

you know, after 2020 and said, hey, we don't, we're not going to invest in this anymore. She said, I have an innovation here that is, is going to work. It's going to bring lower cost, heat stable, domestic manufacturing of tests, not just for COVID-19, but for HPV, HIV, tuberculosis, oncology, and many other disease areas. I'm going to bring that to Africa. And that's what she's doing now. And I'm really proud of her traction so far. She's active in five different countries in Africa. She's working with multiple distributors.

actively growing in Nigeria and Kenya. And it's the kind of innovation that I just don't see in the global health space that much, but it's so essential to global health, right? Like how do we deliver better, cheaper diagnostics that work in an African laboratory where the electricity is unstable, you're not gonna have the air conditioning that you need in order to deliver the diagnostic. And she's addressing that head on, and it's a massive market which will serve Africa better.

and then potentially beyond Africa as well. So I'm really excited about the work that she's doing. I think it's been great to see her grow and grow her team over the time that we've invested. The other example that I'll give is one called AI Diagnostics in South Africa. So they're investing in, so they're building an AI enabled model to detect tuberculosis and other diseases earlier. And if you look at tuberculosis, which I'm sure you know this already, but you know,

spreads through the air, much more dangerous than COVID-19, high mortality rates if untreated. And so much has worked and effort has been done in the global health space around adherence to medications and the Global Fund, et cetera. What these guys in South Africa are saying is, right now, the standard of care for TB,

is you get a sputum test, you send it to a lab, you wait a couple of weeks, you get the results. If you're in the middle of nowhere in your rural area, who knows, you'll get those results in weeks or months. And while that's happening, you'll build up your TB resistance, you're not getting treatment. What if we could detect tuberculosis earlier, non-invasively, instantly with the help of AI? So they're saying if you, so what they're working on is being able to take the sound from a stethoscope, and,

being able to apply an AI model to it, which can detect that disease earlier. They're also building a digital stethoscope, which again, can apply this kind of technology to other disease areas, cardiac, respiratory areas as well. And so a ton of commercial opportunity in Africa and around the world, as well as a smarter, more cost-effective and better quality of life approach for anyone with tuberculosis, because the best way to treat tuberculosis is to find it before it becomes

tuberculosis and squash it early. And that's what they're working on. A solution that can be applied by community workers without a doctor in the picture, just based on the sound of someone's breathing, which I think is phenomenal.

Shubhanan Upadhyay (46:07)
Awesome. Yeah, that sounds really, really exciting. And thanks for providing those kind of lighthouse examples that are exciting you the most. Do you have anything that either kind of didn't work, but you learned something really valuable from that experience, either in terms of when you were like a software engineer, Rowena or in your investor version of yourself?

Rowena (46:26)
Yeah, that's a good question. think maybe one...

I'm not sure if I'm gonna add anything new with this question, but I think one thing that's, one thing I'm currently wrapping my head around and trying to model out the outcomes, you know, from an impact on a financial perspective is that joint investment model for what they call brick and click, you know, so for digitally enabled clinics and how that scales, because there's multiple great examples across the continents, know, Penda Health in Kenya, Yeche clinics in Nigeria,

Shubhanan Upadhyay (46:31)
Yeah. Yeah.

Rowena (46:56)
where they're just delivering primary care, which is essential. That's where the rubber hits the road in terms of healthcare systems. And they're doing it much more efficiently through the use of technology systems. I have not historically, I've not invested in a company like that yet, but I'm really excited by the work that they're doing and by the scalability that they can achieve, particularly if they can package up the work that they're doing and replicate their model, even if they're not, you

building a workforce of 10,000 doctors or buying 1,000 clinics all across the continent. If there's ways to replicate that model, that can leverage both the physical and the digital side by side. That speaks to the point I mentioned earlier about assumptions about working with Africa and how do we fit the old model of VC which was built in California, to the new model of Africa and what Africa needs, not just in healthcare, but in other sectors as well.

Shubhanan Upadhyay (47:42)
so it was really an assumption that you had yourself that has been changed or challenged essentially. Yeah, awesome.

Rowena (47:49)
Yeah, it's being challenged.

It's something I'm grappling with. So if someone is listening to this podcast and wants to walk me through the impact and the economics of it all, by all means, please reach out.

Shubhanan Upadhyay (48:00)
Awesome,

Rowena (48:01)
yeah, I just wanted to throw in one thing since you asked about from my learnings more from when I was building, you know, as a founder, as a product manager. And I think one outcome, which I mentioned, but I think is worth repeating is the mistake is conflating positive health outcomes with a viable organization. Like I wish, I wish it were true.

that demonstrating positive health outcomes and demonstrating it within a certain window and such was enough to get a program funded and scale, our life would be so much easier. We could all just go into the raw science if that were true. The reality that I see in all the markets that I've worked in is that there is a leap. There is the system that delivers healthcare. There is the incentives and the motivations and the budgets and the personalities that are around that.

In order for an innovation with a positive health outcome to scale, you need an organization whose job it is to understand the health system, to work within it, and to win it over. Otherwise, it's not gonna go anywhere.

Shubhanan Upadhyay (49:03)
I really liked that. And you're actually actively challenging an assumption or a natural bias that I have, guess, having a clinical background, which is, look, we're here for the clinical outcomes. We're here. That's what we're all here for. But actually what I hear from your challenge then to my bias would be, well, it's great. We need to have those positive health outcomes. But I very much accept that they take time.

to occur and therefore you need a financially sustainable organisation behind it to then even survive long enough to get to the bit where that's further off down the line. So at least that's definitely a first order takeaway I take away from what you're saying

Rowena (49:39)
Yeah.

Yeah, you need runway for that organization to survive and for the rest of the industry to catch up with it. And you also need to understand the broader ecosystem that will support that innovation. Let me give you an example. So there's a company in Rwanda that has a life-changing innovation, clinical trials have been run on it for neonatal ICUs. It's a medical device, it's fantastic. And if it were in every ICU, then it would undeniably save lives and it would do it in a cost-effective way.

The problem is that nobody in West Africa has ever heard of it. The problem is that the way in which a life-saving medical device, and there are many medical devices that would save a ton of lives in Africa, the way in which they get to market is cloudy. How does a hospital, how does a ministry of health find out about the device? And once they find out about it, how does it get there? Do the trucks that deliver medicine or the other suppliers that deliver beds, do they deliver?

the, do they deliver the device? if they do deliver the device, how are they going to maintain it over time? And certainly there are some devices that have crossed that chasm, but there are so many great innovations that don't. And I think that's a mistake that a lot of founders fall into. It's one of the reasons why as Africa Health Ventures, we invest in distribution channels. Our emphasis is less on medical devices and pharmaceutical development, because that's something that can arise in many different parts of the world.

We believe and we've seen so many life-saving innovations that exist and that could make a difference in Africa. They just can't get where they need to go. And so if you're looking at the whole picture of the health system, and maybe this is something that as an ecosystem we need to work towards as well, you also need to be answering the question of how does it get out there? How does it maintain? How is it financed over time?

Shubhanan Upadhyay (51:33)
Yeah, thank you for sharing that. That's really, really valuable. Couple of other questions. What's your one hot tip for people who are looking to build in this space? You might have covered some of them, but what's your kind of big take, Rowena's big hot tip for people who are looking to build towards underserved communities, either where they are, but maybe in particular in Africa?

Rowena (51:57)
Good question. For those that are more impact oriented, I would say validate the market. I was speaking to an early employee of Wasoko which is a major fast moving consumer goods company. And she was saying, she's working in global health now via global health, their distributor network in Kenya. And she was like, I don't understand how so many organizations in global health have no pathway to market.

It's just not part of something that happens within the first six months or a year of building. And I think that's a fair assessment. So validate the market early on. For those that are more profit oriented, I would say...

be mindful not to create a two tier health system. Like our goal is not just to take the richest of the rich and make them even better than the poorest of the poor. Like part of why we invest in innovations is because we believe the current system is unacceptable. You humanity has already leapt forward and Africa has already leapfrogged forward. And we believe we need to see that leapfrog forward, particularly in the current times in healthcare.

But that doesn't mean that we're leaving most of the population behind. It means we're building innovations that can be scaled through the public systems. We're building innovations that can partner with public systems. We're building innovations that can serve as an example to galvanize governments and public health systems to realize that there is a better way. Because governments were never the place to innovate. And that's another, that's a mistake I people in the global health make. Like the private sector has always been.

the birthplace of innovation and that's what we're investing against. But to the extent that we're impact investors and to the extent that our goal is to scale healthcare, a pure profits founder needs to be mindful of walking that balance in a thoughtful way that isn't excluding parts of the population from the innovation that they're building.

Shubhanan Upadhyay (53:44)
you can see big examples of that in, I mean, the US is a good example. India, I see some of that as well. And yeah, absolutely. How about one hot tip for people looking to think about taking your lead and like, how can I invest in an impact in Africa? How do I go about doing this?

Rowena (53:49)
Yep!

Yeah, I I think what was useful for me was to learn that it's not hard to get started. There are angel syndicates where you can get started with just a thousand dollars or $2,000 and then they pool together. This is very, this is very African, although angel syndicates happen all over the world where you get 20 or 30 people together and they back a startup. If someone's looking to get started, welcome to talk to me. Obviously I have the fund, but always happy to point people, particularly ones that are.

excited about the sector in the right direction of a direct investment that they might be able to make. I think the hardest step is the first, just getting started. Start small, learn a lot, and learn a lot from others who've walked in the space and been in the sector because there's certain eye for investments that you get once you've done a couple.

Shubhanan Upadhyay (54:50)
Awesome, yeah, great advice. Are there other key things that you want to share?

Rowena (54:55)
Yeah, I think just looking ahead to the future and where we go to from here, I think the next 10 years are quite critical. Like you could imagine 10 years from now, Africa is about the same as it is now. The economies haven't developed, it's stuck at the bottom of that development ladder and it's really suffering because the aid industry isn't where we need it to be.

And that is a possibility that can emerge. I can't predict the future, but it's possible that 10 years from now is not so different from today. I think it's also worth looking at the other side of it. So that's my worst case scenario. think let's look at the best case scenario as well. Let's imagine the future that we want to create on this continent. And 10 years from now, it could be a very different picture.

It's human nature to believe that the way the world is when you were born is the way that it's always going to be. Whereas medicine has changed so much over the course of the past hundred years. You know, diabetes care has changed dramatically in the past five years. Cancer care has changed dramatically in the past 50 years. 10 years from now, it can be dramatically different. Like we have the opportunity to set the rails for a quarter of the world's population. We have the opportunity to deliver AI enabled, technology enabled.

information, services, access to care, a lot smarter, a lot faster, a lot better that we have in the past. And Africa, in many ways Africa is where Southeast Asia was 10 or 15 years ago. Africa does have an opportunity to leapfrog ahead if we can address the healthcare gaps, if we can address other challenges in infrastructure and the lack of investment that's happening on the continents. And there's something important about changing,

our mindset, and when I say our, mean both international as well as domestically, you know, within Africa, like what can we achieve here? What would it take? What is that leap forward? And then to act in a way that will unlock that opportunity because Africa already has a track record of leapfrogging ahead and it can do it again as long as it's given the opportunity to do so.

Shubhanan Upadhyay (57:01)
And you've talked about this being a key moment in that opportunity. The shifts that have occurred also create the conditions. mean, so many people were talking about how things can be considered differently and how things can be locally led. And, you know, this is the opportunity for, you know, us to think about this whole space differently and get to the vision that you've talked about.

Yeah, I'm here for it. If you really think that, you know, if we can all work together to get there, that'd be amazing. Awesome. How can people find you and reach out to you or collaborate with you, Rowena?

Rowena (57:35)
Good question. So we have a website at africahealthventures.com. That's the best place to go, particularly if you know of a startup, an early stage startup that's building health innovations for Africa. For me personally, the best place to find me is on LinkedIn. That's where I live. I've given up on Facebook and Twitter. So again, you can find me there at Rowena Luk And then if you're interested, if someone in your audience is interested in just knowing like what's going on on the continent what are some of the exciting

Ventures, what are some of the opportunities for founders and for businesses that are building on the continent? We also released a monthly newsletter. That's africahealthventures.com slash newsletter. And that goes out and that's public. Our goal there is to uplift the whole. Yes. Our goal there is to uplift the whole ecosystem. So we'll celebrate founders, even if we weren't able to invest in them, we'll share opportunities, grants, accelerators, incubators, programs.

Shubhanan Upadhyay (58:15)
I'm subscribed to it. It's a one.

Rowena (58:27)
that are relevant to any founder who's building on the continent. Because if we were 10 times the size, we would be making 10 times the investments that we are. But at least what we can do is catalyze the ecosystem, drive more investment into this space, because there isn't enough that's happening right now. And there's so much opportunity that we're leaving on the table because of that.

Shubhanan Upadhyay (58:46)
Rowena, let me see if I can get my key takeaways off the top of my head from you. It's been so valuable to talk to you. You've given a perspective of how we can think about investment as a way to kind of build up from the ground and serve, the market or serve people where they're at.

And I really liked what you said about meeting people where they are. Secondly, I think I really took away, you challenged my own assumption that I kind of, I'm quick to kind of say, Hey, like we're so, so focused on financial ROI and yeah, you kind of need that in a way, particularly to be financially viable as an, as an organization. you're a builder, make sure you're doing things in the right way to, especially if you accept that.

the bigger health outcomes take a while to get there. Like you need to be around to make sure you realize that. So that's a really good one. And yeah, there's great energy within Africa and

if you're interested in either building or investing, it seems like now is the time because that is where the ball is going to be. it makes kind of an impact for humanity sense. this is an emergent market before it really takes off.

There's definitely a business case there as well. So, so great to hear this nuanced and detailed kind of insight into this perspective, which I just haven't had before. So, yeah, thank you really for sharing.

Rowena (1:00:12)
I love your summary and your recap of all of that. Thank you. And I will say just on the different points that you made, first on the talent, there is so much talent here. I've built global organizations and found the best talent in the world in Africa, not because I was looking specifically here, but because there is talent here. And if they don't have the opportunity to build and to innovate,

then they just go build world-class businesses in other geographies and they'll pop up in Europe and America and elsewhere because they don't see the opportunity on this continent. And we can create that opportunity, particularly investing in the early stages. In that question about markets and meeting the market where it is, I think there's an interesting point there about public healthcare systems and the role of public healthcare systems.

Like it would be ideal, it would be perfect. And I'm from Canada, so you know, I've seen the successes and the challenges of the Canadian healthcare system. But like if we could make dramatically better healthcare delivery work in just the public sector, I'm as strong a proponent as any of making that happen. But we need to meet Africa as it is where it is today. And the fact of the matter is that a lot of public, most public healthcare systems, even in South Africa where I live and the strong economy that it is, it's not working.

The reality is that most healthcare spending, even in the lowest income countries, is out of pocket. And that's something that the global health community largely ignores. It doesn't even work with or collaborate with public private actors, even though the neighborhood chemist is much more top of mind than many other public institutions that are out there. And ultimately it's about recognizing that we need a better solution.

than what's currently available. And the way to do that is to invest in innovation and the private sector has always been the birthplace of innovation. The last thing I'm going to say before I stop yammering is this question that you meant, this point that you made about financial returns. Certainly when I got started in this space, I was so far from that being my goal. If finance was my interest, I would have gone into finance and I'd be making much bigger money on Wall Street than I am right now.

I think what I've come to over the years, first at the organizational level and then at the market level, is recognizing that products and organizations arise from the markets in which they exist. And there's a certain kind of innovation, a certain kind of company that grows within the aid industry, that grows within government, that grows within the private sector. But regardless of where you're working,

you are part of a market, you are accountable to someone. It could be a research founder, could be a donor, but you're accountable to someone. And the thing that you build is gonna be shaped by who you're accountable to. And so the question for anyone who is building or donating or investing in this space is,

who should it be accountable for? Like if we're thinking about the next best way to pay for healthcare, if we're thinking about how do we enable people to take care of themselves more effectively, if we're thinking about how do we get more drugs and devices to market, is the government the best person to innovate in that space? Is research the best person innovate in that space? Is the private sector someone else? But regardless of where you're working, that question of financial returns is always there.

Shubhanan Upadhyay (1:03:42)
Not just in the investment or private market spaces. It's everywhere. So I guess it's a misnomer or a misassumption that it just applies to the private sector. So yeah, good challenge. Rowena, thank you so much. This has been really, really insightful. I'm really grateful that you've taken the time to speak to us on this. Lots of takeaways, whether you're...

Rowena (1:03:51)
Exactly, exactly.

Shubhanan Upadhyay (1:04:11)
investing, whether in policy or whether you're building. So thank you so much.

Rowena (1:04:16)
Thank you, Shubs for having me and for making this podcast possible. I love what you're doing here.