Africa’s Last-Mile Healthcare Gap Is an Investment Problem, Too

By Ajay Wasserman

Africa’s last-mile healthcare gap is not, at its core, a construction problem. It is a coordination problem. And investors who keep financing buildings while ignoring the patient journey inside them will keep getting the same disappointing result: expensive facilities that treat too few people, too inconsistently, to ever become sustainable businesses.

The investable asset was never the clinic. It is the system that makes every single consultation count.

The Scale of the Problem

Primary healthcare, when it works, can meet up to 90 percent of a person’s health needs over a lifetime. That is an extraordinary return on a relatively modest investment – if the delivery system is built to capture it.

Right now, across much of the continent, it isn’t. A 2024 World Health Organization Africa Region report, drawing on the latest available regional data, found that out-of-pocket healthcare costs placed financial strain on more than 200 million people, pushing over 150 million of them into poverty, or deeper into it.

That statistic should stop any serious investor cold. It is not simply a public health failure. It is a capital-allocation failure. The demand for care is not in question. What’s missing is the infrastructure to convert fragmented, unpredictable demand into revenue that is affordable for patients and predictable enough for investors – without sacrificing clinical quality along the way.

What an Investable Network Actually Looks Like

Building a last-mile healthcare network that can attract serious capital requires five things working in concert, not in isolation:

• A hub-and-spoke clinical model. A central clinical hub connected to lighter-touch access points embedded in workplaces, schools, pharmacies, and communities – meeting patients where they already are.
• Task-shifted care, with escalation built in. Nurses and community health workers handling appropriate routine care, with physicians available when a case needs to be escalated.
• A connected patient journey. Diagnostics, digital records, medicine fulfillment, and referrals linked end-to-end, so no patient falls through the cracks between steps.
• Diversified, blended revenue. Income drawn from employers, insurers, government programs, subscriptions, and affordable patient payments – rather than dependence on any single payer.
• Governance that earns trust. Clinical governance and credible local delivery strong enough to drive repeat visits and, crucially, treatment completion.

Miss any one of these, and the model doesn’t scale. It just adds cost.

Investors Are Measuring the Wrong Thing

For too long, “patients reached” has served as the headline metric in African healthcare investing. It is not enough. It never was.

The numbers that actually predict whether a last-mile network will survive – and generate returns – are more granular: cost per patient, clinician utilization, margin by service line, repeat-visit rates, medicine stock-out frequency, collection days by payer, and, most tellingly, the percentage of referrals that are actually completed.

That last figure is the one investors overlook most often, and it may be the most important. A provider can run thousands of screenings and still fail. If nobody owns the diagnosis, the treatment, the medicine fulfillment, and the follow-up, that provider has generated activity – not built a healthcare system.

Matching Capital to the Stage of the Business

Capital structure matters as much as capital amount. Different problems call for different instruments:

• Equity builds the platform, the management team, and clinical governance.
• Equipment finance funds diagnostic assets.
• Working-capital facilities bridge the gap created by slow institutional payments.
• Catalytic capital proves out a new geography or patient segment before commercial capital will touch it.
• Expansion capital should only follow hard evidence – of demand, of collections, of clinical quality, and of continuity of care.

Get the sequencing wrong, and even well-intentioned capital ends up subsidizing inefficiency rather than solving it.

Access and Discipline Are Not in Tension

There is a persistent myth in impact investing that healthcare access and commercial discipline pull in opposite directions – that you can have one or the other, but not both. That myth has cost the sector years of underperformance.

The truth is the reverse. Commercial discipline is precisely what allows quality care to be delivered repeatedly, affordably, and at scale. Without it, even the best-intentioned network collapses under its own weight the moment donor funding dries up.

Africa does not need more buildings labeled “clinic.” It needs connected networks, blended revenue streams, disciplined underwriting, and the patient trust that only consistent, quality care can earn. Get those four elements right, and last-mile primary care stops being a development project. It becomes an investable African asset – one that can finally close the gap that buildings alone never could.

Ajay Wasserman is the Group CEO and Chief Investment Officer of Fio Capital Group, a private family office and investment holding company based in Pretoria. Focused on empowering entrepreneurs and fostering sustainable growth, he believes the future success of global economies depends on the innovation and leadership of private entrepreneurs and businesses.