Discussing Healthcare in Uganda with Dr Chirag Kotecha of UMC Victoria Hospital

Interview with Dr Chirag Kotecha, Director at UMC Victoria Hospital, Avane Cosmetic Dermatology Clinic and Europa Pharmaceuticals

What is your assessment of the healthcare sector as a whole? What are the latest trends?

In Uganda, healthcare is not one of the top priorities in the country for the average person. You have the basic requirements of food, shelter, and then health comes further down. Most of the healthcare in the country is paid for out of pocket by people or by government run healthcare centers. In terms of health coverage, less than 1% of the country has private health insurance. So, for most people, if they want to access healthcare they would have to go to a government facility, which most of the time is overstretched and underfunded because not a lot of the budget goes towards this area. I entered the private healthcare field because there was a large opportunity. The biggest challenge is that most people pay out of pocket. So, for more advanced medical care, they would need to sometimes put other things on as collateral or sell their properties to be able to afford extended healthcare. The biggest challenge comes due to the costs of healthcare in the private sector. In terms of the cost of capital, whether you are trying to raise money for new equipment, machinery, or infrastructure, commercial loans that are available are not necessarily given long repayment periods of 10 years. So, you are passing down the cost to the patient and this becomes prohibitive in most cases. Most of the people in Uganda access healthcare in a time of need. There is no preventative healthcare. With the rise of non-communicable diseases, such as western illnesses like diabetes, high blood pressure, etc., patients are caught with this problem towards the end when things get quite bad. The state of Ugandan hospitals and emergency rooms have improved. The new Minister of Health has implemented many things in the government setting so the government hospitals have a bit more funding which has improved access. The opportunity is that the middle class, especially in urban areas, is growing and they are seeking out affordable healthcare. Most people fly out of the country or have their medical checkups done when they are on holiday. I recognized that there was a need for this market. I started off with a small healthcare center in 2013, which was really an outpatient center. We have expanded it to a full 100 bed inpatient facility covering a variety of services from outpatient to inpatient care. We focused purely on advanced care and now people who are traveling for surgery could have it done locally. We started providing these advanced surgical suites and intensive care units. The challenge still remains the cost. It is a delicate balance to provide quality care at an affordable price and it will continue to remain a challenge in Uganda until we have some form of subsidies or the cost of capital is lower. Ultimately, as healthcare becomes more of a priority, which with COVID it has, this is a nice opportunity for the healthcare sector. Recently, we have had challenges in availability of medications and oxygen supply. The manufacturing sector gets electricity subsidies to be able to manufacture oxygen; however, the healthcare sector does not. There is not enough supply within the country at this crisis. Now, people are realizing that healthcare should be a priority, and it is a good opportunity to put healthcare at the forefront.

What are your specialties at Victoria Hospital? What is your market? How do you distinguish yourself from the other hospitals?

Within Victoria Hospital, we are looking to expand our pharmaceutical business because we have a pharmacy there. Whereas Europa focuses purely on drugs or medications, the Victoria Hospital pharmacy can also import consumables.

UMC Victoria Hospital is a multi-specialty hospital. We have some dynamic partners from India who have investments in other countries and hospitals and they have been onboard since 2017. I ran the business for about five years. Now, these partners do the day to day management and the running of the facility. As a multi-specialty hospital, we do everything from outpatient to laboratory and advanced laboratory. We are one of the three tertiary laboratories in the country. Many tests used to be exported outside the country to South Africa or India. We started doing much of them in the country. We have an advanced radiology suite, an advanced emergency unit, a dialysis center, a maternity unit. We are one of the first to put in a modular operating theatre which would reduce the infection rate almost to zero. We put in advanced HEPA filters and a closed unit with stainless steel surrounding. We are one of the largest intensive care units in the private sector with 12 beds for adults. We have a neonatal intensive care unit for young infants. Our motto is quality, affordable healthcare. We can ensure the quality because with our partners, we have access to capital, access to equipment and machinery, and access to certain high end consumables because they buy them in volume from India where the cost is substantially lower than what we buy locally. We package it together and bring it in to reduce our costs, ultimately passing on that savings to the patients. We have had doctors coming in from abroad for training. Previously, other hospitals would bring in doctors for what they call a “visiting camp”. Doctors come for one or two days and then go back. But, we realized that that was more like a shopping trip for these doctors coming from abroad. We would then keep them here for one year or two years. The intention was to train the local workforce and the local doctors. Now, because of COVID, telemedicine is becoming more and more used across all industries. We are starting to use a lot more of that in terms of Zoom or telemedicine with consultations with doctors in India who can give further expertise and advice on what can be managed. That is what separates us from the rest. We are trying to do everything with a holistic approach to our patients from within: whether you are coming in for your child, mother, yourself, we can get everything done under one roof and provide comprehensive care. That is what we pride ourselves in. When I first started this facility as an outpatient center in 2013, we used to see about 15 to 20 patients a day. Currently, we are seeing 250 to 300 patients on a daily basis in the outpatient setting. In inpatient, from about 100 beds, we usually run at a capacity of about 50% to 60%, depending on the time of the year. We are at a growth stage at the moment. We have overcome a lot of obstacles and challenges as would be faced in a greenfield project. This is our third year now of the hospital so things are going better for us. We are established, we have made a name for ourselves within the community, but the challenges still continue to be there. Those are not specific to our hospital, however. The industry wide challenges which are faced by other providers remain, such as the cost of capital to keep expanding and to keep updating your equipment. In terms of human capital and a trained workforce, we have fantastic doctors within the country, but the support staff sometimes are below what we would want. It is not because of the poor output from the training facilities. It is really because of the brain drain. You have a lot of doctors or nurses who may be exported as human capital or human labor to other countries where they will be compensated or paid better. So, they would continue choosing greener pastures on the other side which leaves challenges locally. With COVID, we see that to be more of a challenge because there has been a shortage of healthcare workforce throughout the world. It is not just in any one country. If they are being compensated better, getting paid better, their quality of life may be better.

Are you looking for partnerships with other hospitals, other clinics, or the pharmaceutical industry?

Ultimately, to improve the quality of healthcare, we do need collaboration, whether it is for any particular field or overall, for advances or new technology. Last year we were looking to collaborate with a facility out of the United States. It was more for R&D. They were looking for data with regards to endoscopies or biopsies of people who have suffered from H. pylori infections. We were also in the initial stages of a discussion with a group out of the United Kingdom who are looking at using technology with watches to be able to detect early maternal infections. In Uganda, many mothers give birth outside of a formal health setting. They deliver at home and many complications arise from that. We are trying to see how we can reduce the complications using artificial intelligence to be able to detect these kinds of infections earlier on. With the advent of the use of artificial intelligence, we can improve the quality of healthcare not only in Kampala and urban settings, but into the periphery regions and to the villages. Technology will help and we do look forward to partnerships with companies who can provide us this kind of expertise.

What are your current projects?

Now, we have two units. We purchased a small hospital about three years ago opposite my main unit. We were planning to use that as a low cost healthcare center. But now, with the COVID crisis, that facility is being used as a COVID center. There are about 35 beds there. The intention for that facility was to make it a doctor’s plaza. We wanted to put in an IVF clinic, an ophthalmology center, with strategic tie ups with doctors or teams who would come in and invest in their equipment and run the facility and bring in the expertise of the human capital. We would like to revisit that, but for now, with the need for housing patients with moderate to severe COVID cases, that is where all our efforts and time are going.

Project yourself to the medium term, three years’ time. What would you like to achieve?

I run another business called Avane Cosmetic Dermatology Clinic where I was the first and probably still one of the few people in the aesthetic field, cosmetic dermatology. It started off more as a side business for me with passive income where I would go in and do a few non-surgical facelifts using Botox and dermal fillers, which are common treatments in the West. It has picked up quite well and the middle and upper class of the country are really getting into it. I get patients coming into Kampala from the Congo, from South Sudan, from Rwanda as well for these treatments. It is a small center with only about eight staff, but it is standing up on its own right. That is a very interesting field to be in, especially now with hopefully this oil sector that is going to take off where there will be a lot of expatriates coming to the country. We can expand Avane regionally as well as into the domestic markets. For the hospital, my intention in the next three years is to double the turnover with more advanced services coming in with the doctor’s plaza. We would like to be able to open up multiple outpatient clinics. We had an intention of opening between five to seven clinics per year. It was supposed to start this year now that we have an established brand; however, due to COVID, that project has been on hold and we would like to revisit that soon. In about three years, I anticipate having at least two more hospitals, and about 15 healthcare centers that will help us achieve this target of doubling the turnover.

Will these facilities be located in Kampala or elsewhere?

With regards to the hospitals, I would like to put a couple more in the big cities such as Mbarara or Gulu. For the medical centers, I would like to have about ten of them within the greater Kampala metropolitan area, and then five spread out to the more second tier towns where there is also a need for medical care.

What major challenges are you facing for Europa Pharmaceuticals?

Europa Pharmaceuticals is another business that I run. It is concerned with importing pharma inputs, such as advanced medications which are not manufactured locally, from India or Australia. The biggest challenge is cost of capital transport. Most of these suppliers want payment upfront or we work on LCs, but by the time the goods come in the LCs have expired. Now, in COVID times, we are reliant on airlifting and the cost is very high.

How are you looking to develop this aspect?

Within Victoria Hospital, we are looking to expand our pharmaceutical business because we have a pharmacy there. Whereas Europa focuses purely on drugs or medications, the Victoria Hospital pharmacy can also import consumables such as items used in intensive care unit breathing operators, endotracheal tubes, etc. Such things can be brought in from abroad. They are lighter, they are more easily used up, and we do not need to bring in such high volumes. In terms of Europa, we would like to bring in more medications. When we started Europa in 2016, we started with six different items that we were importing. Currently, we are doing about 40 and there is a lot more opportunity there as well.

What is your inspiration? What drives you to do what you do?

When I moved back to Uganda in 2011, I remember taking the first amount of money from my family, borrowing about half a million dollars with the intention that in a couple of years I should be able to pay them back. I still have not and we still have to keep asking for more, borrowing more from friends and family, and ultimately from banking facilities. It is a drive that came through because we wanted to provide affordable healthcare and quality care. There was a particularly sad incident where I lost a baby in my arms when I was working at the emergency unit at the hospital and it was really because there was not enough senior medical support for me. I was not an expert in childcare or accessing the baby’s veins, for example. Had I had that support or technology at hand, we could have saved that baby’s life. As a doctor, the first thing that you want to do is to save people, ultimately. I felt that by going into the healthcare sector as a business and by employing multiple doctors or staff, I could do that tenfold. Rather than saving one or two patients myself, I could save several people. That is where my drive came in. In terms of skincare, I also felt that improving people’s self-appearance would improve their confidence and outlook which will ultimately help them achieve their own goals and be satisfied and not succumb to things like depression.

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