One of the main changes in Korea’s foreign affairs in recent years is the expansion of Official Development Assistance (ODA), especially in Africa, which is rapidly expanding. Korea’s ODA to Africa in 2010 was 15% of its total ODA, and it rose to 25% in 2019 as Korea emphasized its role in international development. As Korea’s expansion of ODA and solidarity in international development aid to respond to COVID-19 are related, the expansion of ODA in the African healthcare sector is anticipated to continue. This study analyzed features of the healthcare sector in Africa in an effort to suggest various plans for development cooperation that are based on an evaluation of Korea’s ODA project design to enable the effective provision of ODA.
The contents of the paper are as follows. Chapter 2 examines the five major diseases in Africa and various features of the healthcare sector, such as infrastructure, administrative systems, governance, and policies. The five main diseases in Africa that cause death or burden of disease are neonatal diseases, HIV/AIDS, lower respiratory tract infections, diarrhea diseases, and malaria, and similar results were found in Korea’s five priority partner countries: Ethiopia, Ghana, Senegal, Uganda, and Tanzania. In these five countries, heavy funding from the international community has caused rapid declines in infection rates of, for example, HIV/AIDS and malaria, whereas neonatal conditions and cardiovascular diseases, which have not received similar levels of funding, have exhibited either slow declines or increases. In the case of neonatal conditions, it is essential to have healthcare personnel who can manage births and newborns, but deaths and the burden of disease from neonatal conditions are high due to a lack of healthcare workers. In the case of cardiovascular diseases, deaths and the burden of disease have increased in Africa due to increased vascular diseases, such as high blood pressure and diabetes, as well as overweight and obesity rates. In Africa, most patients suffering from cardiovascular diseases go undiagnosed due to underdeveloped healthcare services, accessibility, and technology, and few diagnosed patients are treated and managed.
There is evidence that the administrative systems in Africa’s healthcare sector in general and in Korea’s five priority partner countries in particular are in a very poor situation. There are poor infection control practices, availability of medical equipment, communication with medical workers in the event of a public health crisis, and health capabilities in primary healthcare hospitals and communities. In addition, the five countries have either no quarantine system or a poor one. For example, they struggle to meet quarantine obligations, perform regular quarantining, and maintain a system related to quarantine detection and response.
Yet healthcare governance of Africa’s compliance with international healthcare norms is at a level similar to the world average. Many countries in Africa, including the five priority partner countries, have national healthcare plans, high compliance with International Health Regulations (IHR), and high financial support against health emergencies. In addition, laboratory diagnostic systems and governance related to public health preparation planning and implementation have shown rapid growth.
The healthcare-related Sustainable Development Goals (SDGs) include comprehensive healthcare improvement measures to achieve reductions in infectious diseases, health improvement, and welfare promotion, such as a reduction in child and maternal mortality; eradication of infectious diseases, such as HIV/AIDS and malaria; reduction in early death due to non-infectious diseases; reduction in health-threatening external factors, such as drug abuse, traffic accidents, and pollution; and adherence to policies of the World Health Organization (WHO) regarding infectious diseases, such as HIV/AIDS, viral hepatitis, and sexually transmitted diseases. Similar to the SDGs, Africa’s Agenda 2063 health strategy includes comprehensive healthcare improvement measures, such as reducing child and maternal mortality, reducing infectious and non-infectious diseases, and improving healthcare systems. The healthcare strategies of the five priority partner countries include specific plans to provide quality healthcare services and increase access to these services. While the health strategies of U.S. and global funds, major donor countries, and donor organizations have centered on prevention, detection, and infectious disease response, the United Kingdom’s health strategy has focused on improving public health and responding to global health threats.
Chapter 3 examines Korea’s African healthcare strategy and the current status of support for the health sector, and on the basis of this, conducts a comprehensive evaluation of ODA provided to the health sector in Africa from an ODA project design perspective. Korea has gradually increased the scale of its aid to Africa by establishing a strategic plan for international development cooperation as the highest level of its ODA strategy. Along with expanding the scale of aid, the Millennium Development Goals (MDGs) have undergone changes over the past decade as more diversified and diverse partnership strategies for African cooperation have been proposed. As demand for healthcare cooperation increased due to COVID-19, Korean International Cooperation Agency (KOICA) introduced the ABC Program to strengthen its ability to prevent and manage infectious diseases and improve quarantine capabilities in developing countries as well as the immediate response to COVID-19. The Export-Import Bank of Korea also prepared healthcare infrastructure support strategies, such as disease management system support, hospital construction, and supply of medical equipment through the Post-Corona EDCF Strategy, and introduced an emergency loan system that can operate at low interest rates.
Korea has provided a total of $670 million to the African healthcare sector over the past decade, reflecting approximately a fourfold increase from $12 million in 2011 to $47 million in 2019. The main areas of support have been different for each partner country, with western coastal countries Ghana and Senegal focusing on drinking water hygiene and eastern countries Ethiopia, Uganda, and Tanzania focusing on general health. When divided into OECD Creditor Reporting System (CRS) target codes, in the case of general health and basic health projects undertaken by Korea, the number of cases of cooperation with public institutions in recipient countries is higher than in other countries, such as the United States, the United Kingdom, and Switzerland. In particular, in the case of general health, cooperation with public institutions is overwhelmingly high at 94.1% of projects. Conversely, in the case of Switzerland, the proportion of cooperation with education and research institutes is 58.8%, indicating a strategic focus on health research. In the case of maternal and child health and population policy projects, the proportion of cooperation through non-governmental organizations (NGOs) and multi-purpose organizations is relatively high, but there has been little cooperation with research institutes or private institutions. Nevertheless, about half of the projects have been carried out through public institutions. In the case of the United States, which has invested $43 billion in African aid for healthcare, evidence indicates that it is carrying out projects through various channels, such as NGOs, private organizations, and research institutes.
Recently, as COVID-19 has amplified the importance of countries’ health and hygiene and ability to respond to health emergencies, the demand for aid in the healthcare sector and the scale of support are increasing accordingly. The necessity of establishing a comprehensive healthcare system under the operation of a simple project unit has also increased significantly. To cope with such changes in the internal and external environments, there is a need to evaluate the project experience and Korea’s present development cooperation plan to determine if they reflect the changing characteristics of Africa’s healthcare sector. Project design is foundational work that can minimize variables that may occur in the operation stage of a project. At the same time, it is an important factor that can give signals to increase the effectiveness of development assistance through business linkage between the recipient country and other donor institutions.
Considering the accessibility and disclosure of data, the evaluation target was limited to KOICA’s projects from 2011 to 2019 in the five priority partner countries including healthcare under Country Partnership Strategy (CPS). The evaluation criteria comply with the OECD DAC’s evaluation criteria, but the evaluation items were adjusted to reflect the areas that the researchers regarded as outliers for effective project design. In addition, healthcare includes multi-layered factors, such as finance, infrastructure, manpower, and system, and since these factors interact differently depending on the nature of the project, similar projects were clustered to understand the characteristics of each cluster. The evaluation revealed that the appropriateness of indicators for African countries’ government policies or strategies of project implementation agencies were considered carefully in the project design stage across all clusters, while efficiency, effectiveness, influence, and sustainability aspects were different for each cluster. In particular, cooperative project clusters conducted jointly with international organizations received higher scores in general on all items than those conducted directly by KOICA. Especially in the case of efficiency, they were intended to increase the effectiveness of the project through a project utility analysis conducted in advance. Population policies and reproductive health clusters directly implemented by KOICA achieved low scores in terms of efficiency, effectiveness, influence, and sustainability, indicating that risk management, administrative regulation, and consistent project design procedures should be considered in the future. However, the analysis indicated that KOICA has already agreed about the need for standardization and that efforts are being made to systematize project design, and the risks arising from the planning stage are expected to improve in the future.
There may be a gap between development demand and supply, and Chapter 4 presents an analysis of the demand for development cooperation in the African healthcare sector. This chapter outlines the demand analysis for development cooperation in the healthcare sector in Africa entailing decision tree analysis and text mining techniques. The results of the decision tree analysis are summarized as follows. This analysis was intended to identify the health needs of each type of African country. First, the most important indicators that can be used in carrying out ODA projects in the health sector are infant and maternal mortality indicators. These indicators are the variables that have the greatest influence on life expectancy prediction and directly affect national competitiveness and GDP per capita. Second, in the five priority partner countries, life expectancy is approximately 64 years old, but if the infant mortality rate is reduced to 28 per 1,000 people, life expectancy is estimated to increase by about nine years. To lower the infant mortality rate, various health ODA projects are needed in the five priority partner countries. Third, when African countries were classified by the decision tree analysis, the group with the lowest life expectancy was only 54 years old. These groups are characterized by countries with higher infant deaths than 56.5 per thousand and higher maternal deaths than 723 (per 100,000 population). There is a need to pay more attention to healthcare projects to reduce infant and maternal deaths.
The subsequent text mining analysis was intended to identify the health ODA demand for each detailed area. In the future, African health demand is expected to have the following characteristics. First, the demand to reduce infant and child deaths and maternal deaths will persist. The need to reduce infant and child mortality is also related to the pregnancy process of mothers. This continues to be a problem in Africa, suggesting that health ODA projects that can solve this problem should increase. Second, there will continue to be a demand for preventive measures against HIV infection. Since more than half of the world’s HIV/AIDS patients are in Africa, there is a need for ODA health projects to prevent HIV infection. Third, there will be a rising demand for water at the group (village, school, etc.) level. The demand for water has been greatly influenced by insufficient water and sewage facilities in Africa and environments in which clean drinking water is difficult to obtain, and the international community is also providing steady support for drinking water hygiene. Fourth, policies, such as case management, are also needed for infectious diseases, such as malaria and tuberculosis. Fifth, there will be a growing demand for nurses, which mainly emphasizes the need for nursing education at local hospitals. This is a problem of strengthening the capacity of nursing personnel, especially at local hospitals. Sixth, there will be an issue of training facilities and manpower at the community level. Seventh, is there is a demand related to governance in the healthcare sector. It can be said that it is related to budgetary problems and governance related to healthcare. These can be said to be problems that can improve efficiency in the process of delivering health services.
Among the above seven demands, infants, three major diseases (HIV/AIDS, tuberculosis, and malaria), and drinking water hygiene have already, for many years, received considerable investments and are of great interest to African countries and the international community. However, the areas of supplying formal health education, facility improvement, and healthcare workers’ training at the community level and healthcare governance were recognized as relatively less important than the demand side.
In Chapter 5, the contents analyzed in Chapters 2, 3, and 4 are comprehensively summarized to derive implications and develop a strategic promotion plan for Korea’s African healthcare ODA. Although the healthcare environment has improved in the five priority partner countries, there is still a high burden of disease, especially due to the prolonged COVID-19 crisis. Consequently, the demand for improvement in the healthcare and communication systems has increased significantly. The U.S. Development Assistance Agency (USAID) and the Australian Development Assistance Agency (AusAID) have identified healthcare governance as a risk factor that may occur in partner countries, and they continue to monitor the healthcare communication system in terms of risk management plans. However, Korea mainly provides support for basic health and maternal reproductive health. Accordingly, it is necessary to respond to the demand for local healthcare governance as well as the existing fields supported by Korea. There is also a lot of room for improvement in universal health coverage and access to emergency medical facilities.
Meanwhile, African countries have consistently spoken out since the 1974 Bucharest Conference, and the African Union specified strategies for improving healthcare through partnerships with various stakeholders to combat three major diseases—namely, malaria, HIV/AIDS, and tuberculosis—in the 2006 Abuja Declaration. In addition, the importance of joint cooperation has recently been emphasized in areas other than these three major diseases and maternal reproductive health, such as eradication of infectious diseases and universal health coverage. Further, the African Union values linking the SDGs to healthcare goals and aims to achieve major goals, such as the Maputo Action Plan; the African AIDS, Tuberculosis and Malaria End Promotion Framework; and African Health Strategies by 2030.
The international community emphasizes access to universal healthcare services, strengthening efficiency in delivering healthcare services, and protecting Africans from public health crises, and goals such as the Triple Billion targets have been established accordingly. It also emphasizes targeting, life-cycle approaches, and approaches tailored to individual characteristics to prevent the segmentation of diseases. As a result, demand for cooperation in major healthcare areas by life cycle is increasing, without neglecting the importance of the three major diseases, and cooperation in other important areas, such as nutrition and health services, infectious and non-infectious diseases, and social services for the elderly, is expected to increase. In particular, Korea’s donation strategy centered on the three major infectious diseases and maternal reproductive health is also expected to require a slight shift, as the burden of diseases and deaths from adult diseases and traffic accidents are gradually increasing in some countries, including Ghana.
Through the 3rd Comprehensive Plan for International Development Cooperation, Korea strengthened strategies, for example, for expanding the size of ODA in the healthcare sector, expanding public–private cooperation, responding to infectious diseases, establishing healthcare systems, and establishing basic hygiene infrastructure. However, to implement more integrated and unsegmented aid, the importance of presenting customized goals along with program access in the healthcare field is also emerging. For example, KOICA is planning a healthcare project focused on intervention in three major areas necessary to lower the maternal mortality rate using Thaddeus and Maine’s (1994) three delays model of maternal mortality. This approach is expected to be necessary not only for maternal deaths but also for areas such as basic health, general health, drinking water hygiene, infectious diseases, and infant deaths. In particular, efforts should be made for the international community and Korea to achieve common goals through healthcare donation projects. For example, USAID is carrying out aid projects by establishing programs focused on activities that allow for meeting mid- to long-term goals in the healthcare sector that will facilitate meeting the core goals. To improve project effectiveness, Korea will also need to approach this on a program basis, but it will be necessary to establish a project design focused on activities aimed at achieving key goals in the healthcare sector.
Meanwhile, for Korea to improve the effectiveness of its aid projects in the healthcare sector, it must accumulate more information on the local area. In particular, to identify the beneficiaries of the project, on-site surveys should be conducted in more depth, but in situations where there are physical constraints, such as the survey period and budget, these are clear limitations to grasping the demands of beneficiaries. Accordingly, alternative data, for instance, from identifying local demand, can be collected through communication with officials of the partner countries. To overcome the aforementioned limitations, it is necessary to utilize not only field experts but also local experts in the pre- or project design surveys and grasp the healthcare status of the project target site through the results of the population and health survey.
Korea will be able to cooperate with its priority partner countries to improve Africa’s healthcare delivery system. For example, Korea has a comprehensive crisis management system for the outbreak of infectious diseases, and a healthcare communication system using digital devices is well established. However, the partner countries have had communications difficulties in responding to COVID-19 despite the digitalization. Therefore, there will be a continuous demand for cooperation in establishing a healthcare delivery system in cooperation with Korea. In addition, it is necessary to strengthen the capabilities of public health centers to strengthen basic medical capabilities. Tier 2 and tier 3 hospitals in the five priority partner countries are mainly concentrated in cities, and accordingly, local residents living in rural areas must seek healthcare services from local health centers. With this in mind, it will be necessary to expand cooperation to strengthen the capacity of community health workers in public health centers. Meanwhile, information and communications technology (ICT)-based pharmaceutical supply chain management will be a promising field for cooperation as ICT can enable real-time management of medical and pharmaceutical products, such as health centers, and prevent delays in treatment due to lack of medicines.
With the COVID-19 pandemic, global demand for Korea’s infectious disease diagnosis, tracking, and monitoring system has increased rapidly, and African countries are no exception. There is an increasing need for cooperation in the formation of infectious disease diagnosis and tracking systems in the five priority partner countries, for instances, to strengthen the capabilities of infectious disease screening centers, build digital platforms, and enhance human resource capabilities. In particular, Korea is developing or testing mobile diagnostic equipment for tropical diseases centered on startup companies, and the establishment of a mobile diagnostic system is expected to be of great help in improving the disease diagnosis rate, especially for African rural residents.
To expand cooperation in the healthcare sector, efforts to link the cooperation sector are also needed. Public health insurance systems have not been established in the five partner countries because they require considerable national funds. However, if there is no public health insurance system, medical service costs are high, and the ratio of self-pay increases, making it highly likely that residents will deplete their financial resources to receive medical services or have very low access to healthcare services. Therefore, it seems necessary to expand cooperation to support the medical insurance system to which local residents can voluntarily subscribe, such as community-based health insurance. In addition, it is necessary to expand public–private cooperation projects in the construction of hospitals. For example, Lesotho’s project to build Queen Elizabeth II Hospital raised project funds by attracting private capital and guaranteed private profits while allowing patients to receive treatment at appropriate costs. There are various methods for undertaking public–private cooperation projects, but it is necessary to respond to healthcare demands, such as hospital construction, by attracting private capital according to the circumstances of each country.
In addition, efforts to enhance synergy effects through a convergent approach are needed. Convergent approaches include links between projects or clusters (general health, basic health, population and reproductive health policy, drinking water and hygiene), links between grant and concessional loan aid, and links between sectors. One example is the linkage between the Export-Import Bank of Korea’s water and sewage infrastructure construction project and KOICA’s water-related education project. Another key cooperation area is the regional development project. This is a program approach in which multiple organizations participate in healthcare ODA projects, and for efficient implementation, an integrated approach is needed, such as establishing a common performance management system from the initial stage of the project (project formation, project discovery, project planning).
Finally, multi-bilateral (multi-bi) aid projects are necessary. The proportion of multi-bi aid in African healthcare ODA exceeds 30%, which can be seen as a result of the aid strategy that takes into account the regional characteristics of Africa and Korea’s aid capabilities. Considering the restrictions on physical accessibility caused by the COVID-19 pandemic, it is expected that the multi-bi aid method will inevitably increase further. For existing bilateral aid projects that are highly workable but face many difficulties in their execution, it is necessary to reorganize them in the form of multi-bi aid with international organizations or to cooperate with only some projects.