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What does it take to become an effective healthcare facility in Africa, where much of the continent is marked by extraordinary needs and limited resources? In a series of profiles, GHCi’s Alex Freedman looks at operations and management strategies at three standout Africa hospitals, in Kenya, Nigeria and Ghana. This profile is the first in the series.

“We’re an American hospital in the heart of Africa,” says Shawn Bolouki, the CEO of Aga Khan University Hospital in Nairobi, Kenya. By “American hospital,” Bolouki means that the facility’s staff-to-patient ratio, its building codes, its safety measures — even its architects — are held to the standards of fully developed nations.

The results have helped make Aga Khan one of the most notable hospitals in all of Africa. In 2013 the hospital became one of only two sub-Saharan Africa operations, and the only one in East Africa, to achieve the much-sought-after and highly demanding accreditation from the Joint Commission International for quality and safety in patient care. (The other sub-Saharan JCI accreditation went to the Lagoon Hospitals Group, in Nigeria.) Bolouki says the hospital is currently applying for accreditation for its pathology and laboratory services from the U.S.-based College of American Pathologists, a respected evaluator of medical laboratory quality assurance.

The hospital’s achievements are helping to raise standards elsewhere in the continent. “We get a lot of requests from other hospitals in Africa to use our hospitals as a benchmark, especially when it comes to quality,” says Bolouki. The opportunity for Aga Khan to be a role model comes as the landscape for African healthcare services is changing dramatically. In Kenya, like many parts of Africa, the rates of noncommunicable diseases in urban middle-class populations are set to outpace infectious diseases and make up the lion’s share of the country’s disease burden by 2027. And according to projections by the Population Reference Bureau, the population in Africa is on pace to double from 1.1 billion in 2013 to 2.4 billion by 2050.

Various players in Africa's healthcare have been stepping up to help the continent to cope via collaboration. “The high growth rate can be a crisis or an opportunity,” says Dr. Amit Thakker, chairman of Africa Health Business, an organization working to establish a development platform for African private healthcare providers. Hospitals across the continent, he says, are looking to new pan-African collaborations for building robust healthcare systems. “You don’t always need to look at Europe, Asia or the U.S. to learn best practices in the health sector,” says Thakker. “Collaboration between African countries provides on-the-ground partnerships, giving Africa a stronger healthcare ecosystem.” Against that background, the presence of a higher-quality provider like Aga Khan takes on added significance.

The amount of care Aga Khan provides is substantial: In 2016, it had 17,000 hospital admissions, nearly 12,000 surgeries, 4,500 deliveries, 3 million lab tests, 1.8 million prescriptions, 120,000 radiation sessions, and over 600,000 visits to its 42 outpatient clinics across Kenya. The hospital provides post-graduate medical training to 100 residents and interns. It boasts state-of-the-art cardiology care as the first facility in East Africa to perform heart-valve replacement surgery via trans-catheter aortic valve implantation (TAVI) in 2015 — a minimally invasive interventional technique approved for use in the U.S. only in 2013. It is the only hospital in the region providing minimally invasive neurointerventional surgery, and it’s the first hospital to use a Trima Accel machine, an automated blood-collection device that extracts the platelets needed in the treatment of leukemia and cancer.

A key element of Aga Khan’s success is that it has achieved high quality while remaining accessible to much of the population and maintaining financial stability. Much of that rounded success is due to the executive acumen of Iranian-born Bolouki, who honed his management techniques in the U.S. He managed acute care and medical facilities throughout California for 26 years, including Tulare Regional Medical Center, CHA Hollywood Presbyterian Medical Center, and Los Angeles County/University of Southern California Healthcare Network. He was CEO of Tulare Regional Medical Center when he left it in 2014 to head up Aga Khan.

When Bolouki arrived in Kenya he took a good, hard look at where Aga Khan might need improvement. “I spent the first month just talking to people,” he says. Based on conversations with everyone, from department chairs and directors to faculty and employees, Bolouki decided to establish a new focus on analytics. He drafted a zero-based budget in which every expense had to be justified by its results. Rooting out opportunities to trim operating costs led to savings of US$8 million in his first six months, he says.

One major element of the transformation: Bolouki had the hospital’s IT team build a management dashboard that displays real-time data on patient numbers, revenue, and costs — and puts the numbers alongside those of other major hospitals across sub-Saharan Africa for comparison. Along with ongoing monthly financial projections from the hospital’s CFO, the dashboard helps his management team make fast, informed decisions to keep the operation in good ongoing fiscal health.

The metrics are openly shared across the organization, in keeping with what Bolouki says is his belief in the importance of managerial autonomy tied to common, interdependent goals. “My understanding with my colleagues is simple,” he says. “You are CEO of your department.” Managers keep track of departmental performance on monthly scorecards, and an all-or-nothing performance bonus goes out only if all managers hit their targets. “That leaves us all interdependent,” says Bolouki. “If one manager doesn’t control costs, then 35 people will get nothing.”

Aga Khan is part of an international family of hospitals and clinics that includes hospitals in Dar es Salaam, Tanzania; Karachi, Pakistan; and Mumbai, India. This hospital network, called Aga Khan Health Services, is part of the larger Aga Khan Development Network, a non-profit whose programs promote health, education, rural development and advancement of the arts in the poorest parts of Asia and Africa. It was founded by Aga Khan IV, the Swiss-born, Nairobi-raised, Harvard-educated imam to Shia Imami Ismaili Muslims, who Vanity Fair estimated in 2013 to be worth US$13.3 billion.

A not-for-profit private institution, Aga Khan accepts both public and private insurance, and also offers discounts to economically disadvantaged individuals paying out of pocket. Last year, 3,700 patients received free or reduced-cost treatment for cancer and heart disease through the hospital’s patient-welfare program. The hospital dispatches mobile clinics to rural areas and provides free preventative care, screening services, and basic healthcare access to 70,000 patients. Its public-good mission reaches across borders, too: When the only radiation therapy machine in neighboring Uganda broke down in 2016, Aga Khan offered free treatment to 400 Ugandian cancer patients.

Geography poses particular challenges. In the U.S., a technical problem with a state-of-the-art linear accelerator for radiation cancer treatment could be fixed in 30 minutes, notes Bolouki. But Kenya lacks trained technicians. “I have to train mechanical and electrical engineers to maintain this equipment,” he says. In fact, Aga Khan develops most of its staff in-house, relying on the local population as much as possible. “Nearly everyone I’ve promoted has been Kenyan,” says Bolouki. “Bringing in expatriates all the time is not the answer.”

While most of Kenya’s healthcare facilities are public facilities, especially in rural areas, the government provides only a third of the country’s total health expenditures. Private hospitals like Aga Khan have become an important part of the Kenyan infrastructure, and account for about another 40 percent of the country’s health expenditures. In general, health institutions in Kenya, which include not-for-profit institutions that offer community-based healthcare services, depend on a wide array of income streams, including the country’s National Health Insurance Fund, private health insurance and out-of-pocket spending.

But Bolouki says that streamlining the hospital’s delivery of services has allowed it to set prices competitively with public facilities. And that, in turn, has increased the volume of services delivered to patients, and driven occupancy rates up from about 65 percent to about 90 percent. “We gained market share, dropped our fixed cost per unit of service, and our margin improved,” boasts Bolouki.

It’s not hard to see why other hospitals are interested in learning from Aga Khan.