Doctor without borders

Innovator and entrepreneur Marie Charles.

'WHEN I became a doctor, I soon realised that I didn't want to treat one patient at a time," says Marie Charles who is now not only a doctor, but also a social entrepreneur and healthcare investor. "I wanted to treat entire nations."

That is still her audacious ambition and she has started to make it happen. Recognised as one of the innovators in global healthcare, she is a regular speaker at universities, international conferences and radio shows and has even had TV documentaries made about her work. It makes a compelling story.

Brimming with ideas, the fast-talking Ms Charles exudes confidence and self belief. We are having lunch, but she has so much to say that she barely allows herself time to eat.

After qualifying as a doctor in her native Belgium, she went on to Columbia University in New York where she got a masters in international relations. She then worked for the pharmaceutical giant Merck at its headquarters in New Jersey.

"I was put on a fast track programme; the idea was to send me to Europe to head one of Merck's facilities there," she recalls. But after five years of corporate life, she decided to take another path. "I realised that I liked the efficiency of business, but I couldn't work for somebody else. I had to create my own work."

In 1997-99, she moved to Kuala Lumpur, Malaysia, where her husband - also a medical practitioner - was working, and travelled around the region. "I got a sense of how healthcare systems looked like in emerging nations, and of the quality of care provided."

From then on, she decided to focus on tackling healthcare challenges in the developing world. After returning to Europe, she headed a research organisation at the University of Amsterdam which, among other things, did clinical studies of HIV-infected patients in Africa.

That was an invaluable learning experience that helped lay the foundations for much of what came after.

"As a research organisation, we had millions of euros being granted to us by EU governments and pharmaceutical companies," says Ms Charles. "We could give medications for free to patients in Africa, as part of the studies that we were doing."

"But when I saw the infrastructure in some of those countries, I realised that no matter how much money you spend, no matter how many medications you carry with you in your suitcase, it wouldn't be effective.

Yes, there were some clinical facilities, there were patients queuing up, there were some healthcare workers and sort-of doctors. But they wouldn't know what to do with the patients."

So Ms Charles decided to find her own entrepreneurial solution.

She explains: "I set up a company called PharmAccess International. I wanted to prove a point to the international community that as long as the infrastructure and systems exist, you can get medications through, you can give money, treat patients and make them better."

She started by focusing on multinational corporations (MNCs) with operations in Africa. Many of them had a presence in multiple places. Heineken for instance, had subsidiaries in nine African countries, including distilleries and bottling plants. It also had healthcare facilities for its workers - though these were rudimentary.

Ms Charles also signed up Joep Lange, a professor at the University of Amsterdam and an expert in the treatment of HIV, which added to PharmAccess International's cache and credentials.

"I persuaded him that we have to make the international community understand that unless you put systems in place, money is wasted and patients don't get treated. He agreed."

Eventually she also convinced Heineken to allow PharmAccess to run all its healthcare facilities in nine countries in Africa.

PharmAccess would put the medical infrastructure in place and train the staff to provide proper care for the patients. "I explained to them that it would be cost-effective and would save a lot of money in the long run." After Heineken, other MNCs came on board, including Unilever and AngloGold.

But up to then Ms Charles was dealing with health issues afflicting mainly the workers of MNCs in Africa. While this was no mean feat, she had bigger dreams.

Going global, getting training right

After selling her stake in PharmAccess to her partners, she set up another organisation with a more ambitious goal: to take reasonably priced, high quality healthcare to the middle classes in the developing world.

The organisation was called Global Medic Force or GMF (www.globalmediforce.org) and was established in 2001, with offices in the US, UK and Hong Kong, where Ms Charles is now based.

In drawing up her modus operandi, she applied some of the lessons she had learned from her observations and experience in the developing world.

"The biggest lesson we learned was about training," she says. "Up to then, the way training was done was that you take the doctors and nurses from developing countries and bring them to the west.

They then get trained in western hospitals. After the training is over - whether it's for six months or 12 months - they are sent back to their local facilities.

"So these people learn perfectly how everything works in the US and Europe where where the infrastructure is in place and all the resources are available. But this is not the case in their local set up. So these training programmes were not that effective."

Ms Charles decided to invert the training model. "Instead of taking doctors from developing countries to be trained in the west, GMF would take experts from the west to train healthcare workers in developing countries, in their local setting.

They would work with whatever resources are available, and then scale up as much as possible while maintaining quality."

The experts - who would themselves be qualified doctors or healthcare specialists - would work as volunteers.

So far, she has managed to sign up more than 1,700 volunteers from 17 countries across the United States, Europe, Canada and Australia. Typically they volunteer for between six weeks and three months per year.

"They go to any type of setting in the developing world," she explains. "This could be anything from a public sector hospital to the smallest community clinic in the middle of nowhere that can take two days and several river crossings to reach.

Some of the facilities even have no electricity, which means you can't provide the best care possible - you just work with whatever exists."

"We carefully screen and select the volunteers - not just by their academic background but also personally, because honestly, not everyone is temperamentally suited for this kind of work. We also screen the countries and institutions that apply to us for assistance.

We sit down with them to ensure that skill transfer is really what they need, not money or equipment. Their responsibility is to ensure that the clinic or hospital is amenable to receiving the volunteers."

The training often starts at a very basic level, but the learning curve - both for the trainers and their students - can be steep.

"In some places, the academic qualifications of the so-called local doctor is two weeks of high school. But within a few months, he or she can be capable of diagnosing and treating basic illnesses with whatever resources are available.

About 85 per cent of the illnesses that people see a doctor for do not require them to go to a hospital; patients can be treated where they live or where they work."

The GMF volunteers work on all illnesses, says Ms Charles.

"Initially it started with HIV and then expanded to infectious diseases. But now they also cover paediatrics, women's health, and general medicine. Not surgery, but everything else at the specialist level."

The changing pattern of illness

There has been a change in the pattern and profile of illnesses, especially in Asia, she points out.

"In Africa, and up to about 10 years ago in Asia, the main problem was infectious diseases. But especially in the some of the faster growing economies in the world, many of which are in Asia, peoples' lives have changed.

Diets have also changed. So now in Vietnam, for instance, 73 per cent of deaths are due not to infections diseases but perfectly preventable and treatable chronic diseases.

In China, the proportion is more than 80 per cent and in Indonesia, 60 per cent. So there's been a shift from infectious diseases to chronic diseases such as diabetes, heart disease and hypertension.

A lot of these can be easily diagnosed and treated, provided there is a place for patients to go."

For a long time, patients had little or no choice. "In Vietnam, about 18 million out of a population of 90 million have diabetes. The total number of doctors in the country who can diagnose and treat this?  85. That's about 220,000 patients per doctor. It's an impossible situation. That's the sort of landscape we're talking about."

According to Ms Charles, in the 12 years since the organisation started operations, GMF volunteers have worked in thousands of clinics across the developing world, mostly in Asia and Africa. "In Vietnam alone, it's more than 200."

Funding has not been a problem. "GMF is set up in such a way that it runs on its own," says Ms Charles. "So, for example when we receive a request, say from an institution in Nepal, we require them to cover the local costs so the programmes almost cover themselves, with very small overheads.

They may get the money from USAID or another donor. If there is an institution that cannot even cover the local costs, we work with them to try and find a corporate sponsor to cover those costs."

But GMF is a non-profit organisation and is limited in terms of resources and therefore, outreach.

Building scale

So Ms Charles decided to raise the ante. In 2009, she set up the Tiger Healthcare Private Equity Fund, with a view to reaching more patients and transforming healthcare systems in the developing world. She sees it as great opportunity, not only as a doctor, but also as an investor and an agent of change.

She pulls from her folder a set of photographs of a crowded street in what looks like a city in Indonesia.

"Look at these pictures, look at these people," she says. "When you consider the fastest growing economies in the world, they have about three billion people who are not the poorest of the poor.

These are the middle classes. They have jobs, they have some disposable income, they can afford to buy a motorbike. Maybe they own a shop, or they are teachers, or factory workers, or white collar workers."

These are the people who need help with healthcare, she says, and they can pay for it.

"For the very wealthy, there is no problem. They can buy a plane ticket and go to Singapore or London or New York. When you're very poor, you're stuck in the covered healthcare sector and you might be benefiting from aid programmes or NGO programmes.

But when you have a job, some disposable income and the latest mobile phone and then you get tonsillitis, it can be a problem - not because you don't want to pay for treatment but because there is no place that gives you quality treatment at a price you can afford.

There are some high-end facilities available. But they charge the price you would pay in Singapore."

With the Tiger Fund, which is headquartered in Hong Kong, Ms Charles hopes to fill some of the glaring gaps in the healthcare systems in developing countries, and help change those systems.

It's a closed-end private investment vehicle, she explains.

"My investors, or Tigers as I call them, are some of the most influential people in global healthcare. I can't disclose the names or the size of the fund, and at the moment it's not open to outside investors.

But she adds that having spoken to venture capitalists, private equity firms, family offices and institutions, she is willing to consider allowing "like minded" investors to participate.

But they must add value, not just provide money. The "Tigers" are not merely rich people, she points out. "They have experience in rolling out healthcare programmes. They know the field. I know each one of them personally and have worked with them in some capacity."

High-impact, high-yield

"We specialise in high-impact, high-yield healthcare facilities in some of the fastest growing economies in the world - mainly China, Indonesia, the Philippines and Vietnam," she says. "We want to distinguish this from the new asset class that is called impact investing.

A lot of projects don't actually have impact in the way we understand the term, nor do they yield good financial returns.

"We invest in commercial enterprises that create the maximum benefit for humanity by changing systems at the national level and international level and make superior financial returns in doing so."

The Tiger Fund does not invest in pre-existing companies, she adds. Rather, it finances companies to fill gaps in healthcare systems. "We identify a gap or a problem, then figure out how we can fix it and develop a solution that gets converted into an investible project."

Quality is key, she stresses. "We control not only the quality of the services provided, but also make sure of the quality of the pharmaceuticals that are prescribed. And we aim to price services at a point where the middle classes can afford them."

She wants her projects to be catalysts of change. "We want to set a standard from day one," she says. "We aim to control at least 5 per cent of the existing healthcare market in the countries where we operate.

When you provide quality care at an affordable price on that scale, then you have enough soft power to force the rest of the system to change."

Thinking big

First as a doctor, then as a social and commercial entrepreneur, Ms Charles has always believed in thinking big, which influences her approach to doing things.

"A lot of entrepreneurs think small from the beginning," she says. "For example if they want to set up a school, they set up one school. Now, the quality control you need for one school is totally different from what you would need if you want to set up 100 schools across a big country like, say, India.

Where will you get your staff? How would you train them, what would be your pricing? You have to think totally differently when you think big. That's what we do.

"I've always said from the beginning that I don't want to treat one patient at a time. I want to treat entire populations. Now I get to do it."

vikram@sph.com.sg

Dr MARIE CHARLES

Managing general partner, Tiger Healthcare Private Equity

1964 Born in Belgium

EDUCATION

1990 MD, Katholieke Universiteit Leuven, Belgium 1992 Masters in International Relations, Columbia University, New York

CAREER HIGHLIGHTS

1998-2000 Chief operating officer, International Antiviral Therapy Evaluation Centre (IATEC), University of Amsterdam

2000 Co-founded PharmAccess International

2002 Founded Global Medic Force

2009 Founded Tiger Healthcare Private Equity fund

AFFILIATIONS

Fellow, Royal Society For Public Health and Royal Geographical Society Henry Crown Fellow, The Aspen Institute

Awarded National Medal of Honour by President of Vietnam for services to healthcare


This article was first published on May 09, 2015.
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