Welcome to Sati - Sourcing Africa to Invest

👋🏾 Marge and Ona here…

We’re both Ugandan 🇺🇬

And through our work at Benue Capital, we’re on a mission to support Uganda’s tech ecosystem and invest in extraordinary founders across Sub-Saharan Africa.

We write Sati to uncover Africa’s history of tech and private investment to understand the present and predict the future.

Join us; let’s see where this ride takes us 🚌

This is the kick-off of our 3-part series on FemTech in Africa.

We’re excited about this one!

Why?

Because we’re highlighting an industry that, from our research, hasn’t received much coverage.

Before we jump in, we’d like to remind you of what we discussed the last time we met.

We wrote a piece called Africa from a Birdseye View: A Macroeconomic Deep Dive to understand the economic drivers of the distribution of VC funding in Africa.

If you’re new with us, you didn’t receive it in your inbox and you won’t find it on our website.

We published it on EiX (Entrepreneurship and Innovation Exchange), a free peer-reviewed resource on entrepreneurship and innovation that attracts close to 5 million visitors a year.

If you’d like to read it, you’ll find it here.

Returning to today’s topic…

The inspiration for this piece stems from a conversation with a FemTech founder who’s built a solution for African women prone to and fighting cancer.

Our research and writing uncovered the following:

In Part 1 of this series, we want you to walk away understanding:

Section 1: Why women are pivotal to improving Africa’s economy

Section 2: The unique health-related challenges African women face that hamper their ability to contribute to economic development

In Part 2, we will share:

Section 3: Non-tech and FemTech solutions tackling these challenges

Section 4: Whitespace for future founders to build

Let’s dive in.

Section 1: Women are pivotal to improving Africa’s economy

For two reasons:

1. Women represent ~50% of the continent’s human resources but contribute 33% to GDP

If more countries focused on advancing women’s health and equality, by 2025 the continent could add $316 billion or 10% to GDP.

2. Women bear life

The better the health of African children, the more productive the continent's workforce and the more fruitful the future economy.

However, a child’s health depends on their mother’s health, starting before conception.

Section 2: African women face disproportionately more health-related challenges than women in the rest of the world

Many African women aren’t provided adequate environments and resources to ensure their health and their children's health.

Therefore, economic development cannot reach its full potential.

Let’s walk through the health-related challenges African women face versus women in other parts of the world by observing:

1. Menstrual Health

2. Fertility and Adolescent Pregnancy

3. Sexually Transmitted Infections

4. Maternal Health

A woman can get pregnant when she ovulates for the first time, which is ~14 days before her first menstrual period. This can happen as early as 8 years old or even earlier.

The challenges

Depending on the culture, as soon as a woman starts to ovulate, she’s seen as a potential bride and/or sexual partner.

Beyond the risks of early sex, menstruating girls in many African countries experience period poverty, meaning many African women cannot afford to purchase sanitary products or manage their periods with dignity.

In 6 of 11 countries studied by the BBC, women on minimum wage spend between 3-13% of their monthly salary to buy two packets of sanitary towels, the average a woman needs each month.

This study looked at the cost of the cheapest sanitary pads and found they were beyond the reach of many women.

In Ghana, which has the least affordable menstrual products of the countries surveyed, the average minimum wage per month is ~$26. A 2016 study suggested that 76% of urban employees received minimum wage.

One woman explained that she could previously purchase sanitary pads when they cost 4.88 Ghanaian cedis ($0.45) per pack.

But when the government increased taxes on sanitary products, a single packet increased to 20 cedis ($1.84), pushing them above her means.

Why taxation on feminine hygiene products matters

Taxation increases the cost of products.

Some governments see feminine hygiene products as luxury items rather than consumer goods. Therefore, they receive the same taxes as items considered non-essential.

In 2004, Kenya became the first country in the world to remove tax on period products. In 2016 it went further and removed tax on raw materials used to manufacture sanitary pads.

Consequently, today, Kenya has the cheapest period products for 50 Kenya shillings ($0.35).

The impact of period poverty on African women

Due to cash constraints, some women attest to exchanging sex for funds to purchase pads.

Outside of trading sex or other forms of work for pads, women resort to alternatives, such as chicken feathers, mud, and newspapers, or reusable pads like old clothes and pieces of blankets.

The lack of adequate sanitation facilities in schools and public places further complicates menstrual hygiene management.

This scarcity results in frequent school absences for girls during their periods, disrupting their education and future employment opportunities. Early school dropout often leads to early marriage and childbearing, limiting a girl’s economic potential.

In workplaces, insufficient sanitary facilities hamper productivity, causing wage loss and hindering career advancement.

Published texts, talks, and podcasts often harp on Africa’s rapidly growing population. It is expected to nearly double by 2050 to 2.5B and is forecasted to be home to 1 in 3 youth (between 15 and 35) globally.

The only way these statistics can be achieved is through high birth rates.

Birth rates in Sub-Saharan Africa have decreased over time, yet remain significantly higher than other regions.

Additionally, adolescent pregnancies are higher in Sub-Saharan Africa than anywhere else.

Adolescent pregnancy poses public health risks, including higher maternal mortality, low birth weight, and severe neonatal complications. It can also adversely impact mental, physical, and social well-being, and remains a leading cause of death amongst adolescent girls globally.

Additionally, like period poverty, adolescent pregnancy limits access to education, employment, and financial independence.

Factors that contribute to high rates of adolescent pregnancy vary by country but can be broken down into 3 major buckets:

1. Rate of child marriage

2. Poverty rate

3. Years of schooling

Note: In our analysis, Niger, Mali, and Chad had high rates of adolescent pregnancy and high rates of the factors mentioned above.

1. Child marriage contributes to adolescent pregnancy

Girls subject to child marriage typically come from backgrounds with limited education and reside in impoverished, rural areas.

In some cases, families in poverty marry off their daughters to receive dowries.

Within these marriages, early pregnancies often result from familial or spousal pressure to start families or demonstrate reproductive potential.

2. There’s a correlation between a country’s poverty rate and adolescent pregnancy rate

NIH studies uncovered a relationship between poverty and coerced sexual relations with older men as a means for adolescents to meet their basic financial needs.

Research also found that some adolescent girls intentionally become pregnant to receive government support grants intended for teenage mothers.

3. Lower levels of education are associated with adolescent pregnancies

Adolescents with higher levels of education are more likely to delay the onset of sexual relations and marriage. They tend to be more informed about their rights, reproductive health, timing of marriage, and pregnancy.

Over 30 bacteria, viruses, and parasites are transmitted sexually, with some also passing from mother to child during pregnancy, childbirth, and breastfeeding.

8 pathogens are linked to the greatest incidence of STIs.

4 are curable: syphilis, gonorrhea, chlamydia, and trichomoniasis.

4 are incurable: hepatitis B, herpes simplex virus (HSV), HIV, and human papillomavirus (HPV).

Sub-Saharan Africa records the world's highest STI rates, particularly among women.

The African woman’s experience with STIs is characterized by late diagnosis and treatment. When untreated, curable infections can lead to infertility, cancer, and other complications, as well as increased vulnerability to HIV.

Below, we dig deeper into HIV and cervical cancer, two diseases that take major tolls on African women.

HIV

The prevalence of HIV has always been highest in Africa. It accelerated in the 90s, peaking in the 2000s.

The rollout of HIV/AIDs treatment in the developing world saved millions of lives

In 1987, the first antiretroviral (ARV) drug to treat HIV/AIDS was the most expensive drug in history, costing a patient $10,000/year.

In 1988, at the International AIDS Conference in Stockholm, there was debate about how to ensure people in developing countries could access the treatment. It was considered far too expensive for resource-limited settings.

UN agencies, academics, and major donors all argued against providing treatment in favor of focusing funding on prevention. As a consequence, many high-prevalence countries were slow to adopt national treatment plans, and many people continued to die.

In response, activist demonstrations took place worldwide to raise awareness of the global inequities in access to treatment.

In early 2001, widespread access to affordable ARVs became feasible after an Indian generics manufacturer announced that it could make ARVs for less than $1/day. However, cheaper ARVs weren’t immediately attainable in some countries.

In South Africa, home to the largest number of people living with HIV/AIDs, cheaper ARVs became accessible in 2002 after a landmark legal victory. The government successfully contested against 39 pharmaceutical companies, enabling a law to source more affordable ARVs.

Since 2003, international funding has supported widespread distribution of ARVs. Over 80% of ARVs in low and middle-income countries come from cheaper Indian generics. The dramatic reduction in the cost of treatment from $10,000 per patient/year to almost $50 has saved many lives.

HIV among women in Africa

Women and girls (ages 15+) account for 62% of all people living with HIV in Sub-Saharan Africa.

Women continue to bear the brunt of the epidemic, with young women infected almost 10 years earlier compared to their male counterparts.

The social stigma surrounding HIV/AIDS in Africa leads to severe consequences for infected women, including the break-up of families, abandonment by husbands, loss of inheritance, and social exclusion.

A multitude of factors increase women’s vulnerability to HIV acquisition. They include:

1. Biological risk factors:

Women are at a greater physiological risk of contracting HIV because they have a greater mucosal surface area exposed to pathogens and infectious fluid for longer periods during sexual intercourse and are likely to face increased tissue injury.

2. Contextual risk factors

In many African societies, patriarchal norms often diminish women's agency in sexual decisions. Women risk violent repercussions for initiating sex, proposing condom use, or rejecting sexual advances.

In some cultures, men are positioned as family heads, decision-makers, and financial controllers, while women are expected to respect their husbands, accept polygamy, and perform family and community duties.

3. Socioeconomic risk factors

Poverty also contributes to HIV transmission in women.

Low economic status is associated with earlier sexual experience, lower condom use, multiple sexual partners, higher incidence of the first sex act being non-consensual, and a greater likelihood of transactional or physically forced sex.

HPV and Cervical Cancer

We’re highlighting HPV because it’s the cause of over 65% of cervical cancer cases in Sub-Saharan Africa, the leading cause of cancer deaths among African women.

Africa has the highest incidence of cervical cancer in the world.

As well as the highest rates of death.

Every year ~118,000 African women are diagnosed with cervical cancer, and ~65% die from the disease.

Cervical cancer can be prevented through:

1. HPV vaccination

2. Screening and treatment of precancerous lesions

3. Early diagnosis and treatment

Barriers to prevention

1. Lack of progress in the implementation and performance of HPV vaccination programs

HPV vaccines became available in 2006. Data indicates that the vaccine cuts cervical cancer cases by ~90%.

However, the high cost of the vaccine has hampered uptake in Sub-Saharan Africa as many countries cannot afford the negotiated $450 per dose.

Other explanations include:

• Lack of awareness and education on the benefits of the vaccine

• Lack of awareness of where to receive the vaccine

• Fear that vaccine could affect fertility

• Inadequate cold chain capabilities

In 2011, Rwanda was the first Sub-Saharan country to introduce the vaccine. Subsequently, there has been a slow increase in the number of countries adopting the vaccine each year.

2. Low uptake of cervical cancer screening

Although screening has proven to reduce cervical cancer incidence, coverage is limited in developing countries. Average screening rates are 19% compared with 63% in developed countries.

In Sub-Saharan Africa, screening coverage is ~10%.

Factors for low uptake include:

• Lack of formal education

• Lack of awareness of where to get screened

• Negative attitudes and perceived susceptibility

• Whether the provider screening was male

• Facilities with overcrowding and overburdened healthcare providers

• Fear of hidden charges was a barrier

Having a child is monumental and, for many women, the greatest joy in life.

Women living in the West are offered a range of services to ensure safe delivery, leading to low levels of maternal death.

However, for several reasons, maternal mortality is disproportionately higher in Sub-Saharan Africa.

Maternal mortality refers to the death of a woman as a result of pregnancy or delivery and includes women who die within 42 days of the termination of their pregnancy.

According to the WHO, Sub-Saharan Africa accounted for ~70% of global maternal deaths in 2020. Most deaths occur due to severe bleeding (hemorrhage), hypertensive disorders in pregnancy, and pregnancy-related infections.

Most deaths are preventable and occur due to:

1. A lack of resources to provide quality care

2. Patient-related factors such as the ability to afford care

Hemorrhage, the leading cause of death, is typically associated with a lack of resources

1. Unskilled delivery assistance

Sub-Saharan Africa suffers from a lack of skilled healthcare providers due to poor working conditions and inadequate pay. Additionally, staff recruitment and retention is a challenge.

2. Delivery in ill-equipped facilities

Women giving birth frequently encounter delays in accessing necessary care.

Many deliver at home, and in cases of complications like hemorrhage, there's often a delay in presenting at a health facility.

Even when a woman reaches a health facility, it might lack critical resources like transfusion blood, necessitating transfer to another center with adequate care.

This delay can be fatal.

For example, in Guinea, maternal death odds were significantly elevated in cases that involved transfer to another hospital.

Hypertensive disorders are the second most common reason for pregnancy-related death

These conditions should be diagnosed and treated early in prenatal care.

The WHO recommends at least 4 prenatal visits, yet most Sub-Saharan countries have low coverage of prenatal care.

Factors that increase the likelihood of prenatal care include a woman’s income bracket, education level, and residence (urban versus rural).

A deep dive into statistics and associated challenges revealed a potential chain of effects:

Women tend to fall into two camps: high-income or low-income.

Track 1: High-income women are more likely to have:

1. Access to menstrual products

2. Stay in school

3. Earn income and contribute to the economy

Track 2: While low-income women are more likely to:

1. Experience period poverty (Issue 1: Menstrual Health Challenges)

2. Spend less time in school and fall into earlier sexual relationships, sometimes through marriage

3. This leads to adolescent pregnancy and higher lifetime risk of maternal death (Issues 2 and 4: Adolescent Pregnancy and Maternal Health)

4. As well as a higher likelihood of contracting STIs that could result in HIV and cancer (Issue 3: STIs)

39% of women in Sub-Saharan Africa live in extreme poverty, or on less than $2.15/day. Meaning a significant amount of women are at risk of falling into track 2.

This is not to say that women in track 1 aren’t also at risk of the early onset of sexual relations, pregnancy, STIs, and cancer.

But now we understand the demographic and structural drivers that contribute to the health-related challenges African women face.

When we regroup, Part 2 will discuss:

Section 3: Non-tech and FemTech solutions tackling these challenges

Section 4: Whitespace for future founders to build

Bringing us full circle, these solutions will play a role in allowing more women to contribute to the economy, reaching the 2025 goal of a 10% increase in GDP or $316B contribution to Africa’s economy.

That’s all we have for you this week!

Thanks so much for making it to the end!

If there’s anything else you’d like us to explore, send us a note. We’d love to hear from you! You can find us on:

• Twitter: Marge, Ona

• LinkedIn: Marge, Ona

• Email (Reply to this email)

If you enjoyed this piece, make sure to sign up to get more like this in your inbox soon!