Another opportunity for significant positive change lies with public investment banks. If banks such as the European Investment Bank (EIB) or the Council of Europe Development Bank (CEB) shift their approach from traditional ‘hard’ infrastructure investments to support ‘soft’ investments, this could have a positive impact on health and wellbeing. Public Investment banks, such as the EIB, the CEB, the national promotional investment banks and others make investments in the health sector. These investments, however, tend to finance expensive ‘hard’ infrastructures, such as hospitals, and innovation coming from medical research, technology and equipment, health informatics and medical training. Large investments will now also go to crisis preparedness following bio-medical models. While important, these investments usually have less impact on the reduction of health inequalities. Investments into more psycho-social approaches of health, wellbeing and resilience are going to be scarcer.
However, public investment banks are changing. Thanks to their experiences with the benefits of ‘green investments’ in the climate and infrastructure sectors, public investment banks are increasingly exploring the benefits of similar socially-conscious investments in the health and social sectors. For example, in Ireland, 14 new primary care centres are to be built following agreement of a €70 million 25-year loan from the European Investment Bank.
European Investment Bank financing of Primary Care Centres, Ireland
14 new Primary Care Centres are to be built across Ireland following agreement of a new €70 million 25-year loan from the European Investment Bank in 2018. This represents the EIB’s first support for healthcare investment in Ireland and the first dedicated backing for primary health care anywhere in Europe. The new public-private partnership (PPP)-based scheme will support the shift from hospital-based healthcare to community-based care closer to patients. The new Primary Care Centres are to be built in Sligo, Roscommon, Mayo, Galway, Limerick City, Waterford City, Tipperary, Wexford Town, Kildare and Dublin. They will provide basic health services, including GP surgeries, occupational therapy, social work and dietary advice. In some locations, additional services will also be provided, including mental health, dentistry, addiction services and a local ambulance base.
Financing from the EIB represents 49.5% of the total investment cost of the new facilities. The project will be co-funded by commercial lenders. This is the second healthcare project to be backed by EFSI.
One or several local and regional authority/ies could group together the investment needs in a variety of different sectors over which they have responsibility (either to provide or fund, or both) and request a loan directly. The EIB loan to the Irish National Development Finance Agency to build 14 primary care centres across the Ireland is a good example of how Irish authorities grouped together what could have been different investment projects. Another example is the EIB Framework loan to the town of Orebro in Sweden, who requested a €180 million via a 25-year-longloan to invest in 40 small to medium size schemes in education, childcare, and municipal housing.
Local and regional authorities are not the only bodies able to bundle projects together. With the right push for providers and enterprises requiring loans, banks can also bundle different projects together or see potential for such development access support from the European Investment Bank. One example of this is Belgian bank Belfius’ smart and sustainable cities programme where Belfius and the EIB invest together in over 100 different projects from a wide range of sectors: environmental, health, retirement care, and digital. Another option is for the service providers themselves to group their investment needs together and create a special purpose vehicle able to request financing from an investor.
Whilst there are some potential examples, this avenue remains largely unexplored; partly explained by the lack of support and capacity-building to such bundling by local and regional authorities. Some authorities are currently exploring how they could fund such developments, through for instance the Technical Assistance budget of the European Social Fund.
The European Investment Bank is the European Union’s public lending institution, whose shareholders are the Member States of the European Union. The EIB should not be confused with the European Central Bank, whose main task is to maintain price stability in the euro. In short, the EIB is the European Union’s bank and therefore works closely and increasingly with the other EU institutions to implement EU policy.
The EIB is also the world’s largest multilateral borrower and lender and offers 3 main types of products and services:
- Lending – about 90% of its total financial commitment
- Blending – allowing clients to combine EIB financing with additional investment
- Advising and technical assistance – maximising value for money.
The EIB makes loans directly to project promoters (public, private, not-for-profit)-primarily above €25 million. When smaller loans are involved, the EIB opens credit lines for financial intermediaries (often, national or regional banks) who then provide cheaper loans to enterprises (public, private, not-for-profit). This is done through the European Investment Fund (EIF), whose main aim is to support Europe's small and medium-sized businesses by helping them to access finance.
The EIB prioritises four main areas, namely innovation and skills, small businesses, infrastructure, and climate and environment. It is also active in healthcare, having – according to their statistics – helped to improve healthcare services for 27.3 million people in 2018.
The EIB works on three main principles which guide the selection of projects for financing:
- Projects which enable universal access to effective, safe and affordable preventative and curative health services;
- Projects which provide sustainable health services;
- Projects with the highest expected economic value for society, taking into consideration outcomes and impacts, such as health outcomes, employment creation and social gains.
The EIB is specialist provider of finance to benefit small and medium-sized enterprises (SME) across Europe. As part of the EIB Group, their shareholders are the EIB, the European Union represented by the European Commission, and a wide range of public and private banks and financial institutions. It support sSMEs with either their own resources or those provided by the European Investment Bank, the European Commission, by EU Member States or other third parties.
They have two specific objectives:
- Fostering EU objectives, notably in the field of entrepreneurship, growth, innovation, research and development, employment and regional development;
- Generating an appropriate return for our shareholders, through a commercial pricing policy and a balance of fee and risk-based income.
The EIB will be the main implementing partner for the European Commission’s InvestEU programme that is part of the 2021-27 multiannual financial framework. The agreed proposal reached by the Council, the European Parliament, and the European Commission approves the EIB Group as the main partner for 75% of the InvestEU programme. The EIB will provide technical support to project promoters under the InvestEU Advisory Hub (see Annex 5 for more information on InvestEU).
A new initiative led by a hospital in Treviso, Italy, demonstrates the openness of the EIB to exploring “soft” infrastructure and is another example of a sustainable public health infrastructure project. A social impact investment model for Treviso hospital is derived from savings from the EIB financing and re-investment of funds in social entrepreneurial initiatives involved in the public health field in the community.Similarly, the CEB is providing budget support to the Autonomous Region of Madrid, thereby contributing to social cohesion through improved social care services to vulnerable people in need.
However, it must be noted that such opportunities are likely to be highly competitive and inaccessible to programmes with modest budgets and limited capacity to ‘speak’ the language of the finance and investment sector.
The Council of Europe Development Bank (CEB) is now also dealing with more complex and integrated projects, blending ‘soft’ and ‘hard’ infrastructure components, and is increasing its emphasis on targeting specific vulnerable and isolated populations. As a multilateral development bank with a purely social vocation, the CEB provides governments, local or regional authorities as well as public or private financial institutions with loans for social projects. The borrowers are generally the beneficiaries of the loans they receive, but they can also act as project promoters on behalf of one or several final beneficiaries.
The CEB bases its activity on its own funds and reserves and receives no aid or subsidy from its member states. As a non-profit driven institution, the CEB applies only a limited margin to its loans and charges no fees, thus enabling its borrowers to significantly reduce the cost of the loans they take out to finance social projects.
The CEB represents a major instrument of the policy of solidarity in Europe. With the aim of strengthening social cohesion, the CEB contributes to the implementation of socially oriented investment projects through four sectoral lines of action: strengthening social integration, managing the environment, supporting public infrastructure with a social vocation, and supporting Micro-, Small and Medium Sized Enterprises.
These include projects targeting, among others:
- people from disadvantaged backgrounds,
- vulnerable groups and people with disabilities,
- unemployed people through job creation,
- homeless and refugees,
- elderly people.
A recent project the CEB has co-financed is the development of primary health care facilities in Bosnia & Herzegovina1https://www.investopedia.com/terms/i/irr.asp. This included rehabilitation, medical, and IT equipment for family medicine facilities (ambulantas), and training for doctors and nurses in Family Medicine specialisation. The project was part of the “Health System Enhancement Program” (HSEP), elaborated by the Government of the Federation BiH and Republika Srpska with support from the World Bank, the CEB and local Governments. The CEB funding involved two loans approved in 2005 (US$ 14 million) and in 2011 (€ 9.2 million).
The project was co-financed by the World Bank and the low interest rates help the government to manage repayments from central funds.