kenya translational research | 1 authors: Katusha de Villiers translatable lessons Athenkosi Sopitshi Dr. lindi van niekerk from the kenyan rachel chater healthcare landscape OCTOBER 2015

“Translational models of primary care: Understanding the replicability and scalability of high impact private sector business models for low-cost primary care, developed and implemented in Kenya, within the South African healthcare landscape.” OCTOBER 2015 EXECUTIVE SUMMARY

South African policy makers can take advantage of the lessons learned from the Kenyan health care system, and its relationship with the private healthcare sector.

y breaking down the Coordination of care would relieve siloes that exist within the burden on a system that is the sectors of health care suffering from severe capacity delivery, an open dialogue constraints xxxvii, would provide Bcan be created that will promote support through leadership and transparency, build trust, and mentoring to those health care ensure the recognition that across providers and ultimately allow for the sectors there exists similar the optimal delivery of patient- agendas; focused on providing centered care. Learning from the health care to all members of the lessons provided by the Kenyan national population. healthcare system, it is arguable that private sector healthcare There are many different providers – whether Kenyan mechanisms and models that have or South African – are ready to been and can be used to stimulate provide priority health services participation by the private to underserved populations who healthcare sector in supporting have evidenced the willingness and supplementing the goals of to pay for this care provision. the public sector. There will always However, this opportunity must be be those healthcare consumers supported by policies and market who fall at either end of the conditions that will allow private healthcare provision network, healthcare providers to support i.e. solely private or solely public, the goals of the South African but there is a gap which may National Health Insurance plan. be characterized as the lower- middle class or the working poor. The individuals who exist within that economic band are able to purchase primary care services from the private sector using discretionary funds while still not being able to afford or being willing to purchase healthcare insurance.

xxxvii Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa. World Bank, 2011 kenya translational research | 3

1 INTRODUCTION

The future success of the South African HEALTHCARE SYSTEM lies in understanding the issues of interdependency and sustainability – and in having the courage to make innovations possible.

he evolving health landscape in South Africa and the reforms being undertaken to prepare for Ta National Healthcare Insurance, presents the opportunity to understand effective models of care provision as developed in other African contexts and translate the applicability of these models as appropriate to the South African environment. A main focus of the South African Ministry of Health in regards to the National Health Insurance is the delivery of high-quality accessible primary care to all citizens and, thus, research on translational models of primary care would hold value for local policy makers. Kenya’s health care is organized primary care services, and county as a devolved system. In 2010, referral systems. Kenya’s innovative approach to the provincial, district, and local primary health care provision is government administrations Kenya’s private health care particularly ripe for examination, were replaced by the county sector is extremely dynamic and as, contrary to the South African administrative structure. At a the Kenyan government has health system, almost half of national level, the Ministry of recognized the critical role that Kenya’s poor utilizes the services Health provides leadership; key the private sector plays in the provided by the private health mandates include development provision of care to even the sector. There could further be of national policy, provision poorest citizens. Kenya’s Vision other key lessons that South Africa of all technical support, and 2030 plan specifically contains could gain in regards to the policy M&E activities for all health strategies to develop the private and regulatory environment and care provision. The national sector. These strategies include the innovation ecosystem of other government is also responsible social insurance, a reduced African countries. For example, for all national referral systems. role for the Ministry of Health in mobile health has been used County health departments are delivery of care, and promotion of more extensively in countries responsible for providing the a greater number of public-private such as Kenya and Uganda, as institutional and management partnerships. compared to South Africa, to structures necessary for health support care delivery of care in care delivery while also overseeing low-income communities. community health services, 2 Country Health System Background

It is generally recognized that the structure of a health system, and the nature and extent of health reforms undertaken, may all affect the ability of the system to respond appropriately to challenges and opportunities for reform. i

broad comparative overview of the Kenyan DATA POINTS and South African health care systems, Atheir histories, current state, and associated challenges proved helpful in highlighting the commonalities and divergences between the two countries. 45,925,301 TOTAL POPULATION Context and setting

Kenya is situated right along the equator, on the eastern coast of the African continent. It has a population of 44.4 million people. Kenya has had some success in reaching Millennium Development Goals such as reduced child mortality, near universal primary school $3,100 enrolment, and narrower gender GDP PER CAPITAL gaps in education, and has decreased its poverty rate from 40% 47% in 2005 to 34-42% in the UNEMPLOYMENT most recent household survey ii. RATE Within the continent, Kenya has seen steady growth economically and its government has continuously shown commitment towards driving development. $45

HEALTH 4.5% EXPENDITURE PER PERSON HEALTH AS A % OF GDP

i Dawad, S. and Veenstra, N. Comparative health systems research in a context of HIV/AIDS: lessons from a multi-country study in South Africa, Tanzania and Zambia. Health Research Policy and Systems 2007, 5:13, ii World Bank, 2013 kenya translational research | 5

1(Central Intelligence Agency 2015) 2 (World Bank 2015) 3 (United Nations Development Programme 2014) 4 (United Nations Children’s Fund 2014) Country 5 (Joint United Nations Programme on HIV and AIDS 2014) Overview 6 (World Health Organization 2012)

COMPONENT DETAILS/ INDICATOR DATA

Population Total population 45,925,301 (2015)1

Rural vs Urban 25.6% urban, 74.4% rural (2015)1

Geography Eastern Africa, bordering the Indian Ocean, between Somalia and Tanzania1

Ethnic composition Kikuyu 22%, Luhya 14%, Luo 13%, Kalenjin 12%, Kamba 11%, Kisii 6%, Meru 6%, other African 15%, non-African (Asian, European, and Arab) 1%1

Government Kenya is a republic, with governance over 47 counties and the capital at Nairobi. President Uhuru Kenyatta serves as chief of state and head of government; president is elected by a popular vote for up to two five-year terms. Parliament consists of the Senate, elected by a proportional representation vote, and the National Assembly, elected by a simple majority vote. Highest court is the Supreme Court, whose justices and judges are nominated by the Judicial Service Commission and appointed by the president.1

Economic Situation GDP per capita $3,100 (2014 USD, 2014)1

Economic growth % in GDP 5.3% (2014)2

Gini-index 47.7 (2013)2

HDI 0.535 (2013)3

Number of people living on <$ 1 / day 43.4% (2012 est.)1

Unemployment 40%1

Total 78% (male: 81.1%, female: 74.95%, Adult literacy 2015)1

Girls vs Boys education 98% (2012)1

Access to improved drinking water: 61.7% (urban: 82.3%, rural: 55.1%, 2012)1 % population access to sanitation Access to improved sanitation facility: 29.6% (urban: 31.3%, rural: 29.1%, 2012)1

Health System Health as % of GDP 4.5% of GDP (2013)1

Annual public expenditure on health (%) 41.7% (2013)2

$ health expenditure per person $45 (2013)2

No doctors/1,000 population 0.2 physicians/1,000 population (2013)2

No nurses & midwives/1,000 population 0.9 nurses/1,000 population (2013)2

% births with skilled attendance 44% (2008-2009)4

Infant mortality rate 39.38 deaths/1,000 live births (2015)1

Under 5 mortality rate 71 deaths/1,000 live births (2013)2

Average life expectancy 63.77 years (2015)1

Disease burden HIV/ AIDS prevalence among adults aged 15 5.3% (2014)5 to 49

Deaths due to AIDS 33,000 (2014)5

Maternal mortality ratio 400 deaths/100,000 births (2013)2

Deaths to non-communicable disease 98,400 (2013)6

Deaths due to homicide 3,174 (2012)6 2 country health system background... continued

Organization of In addition to these services, rates. Approximately 25 percent Health Care there are private and faith based of the HRH budget for the entire organizations (FBOs) that work public sector is taken up by the The tiers in Kenyan health with the national and county two referral hospitals v”. system defined in the Kenya Ministries of Health. According to Health Policy are PEPFAR, FBOSs make a significant Moreover, drug regulation and contribution to healthcare delivery availability remains a problem in Kenya. despite regulation policies. Community level Kenyan citizens, especially those The Kenya Episcopal Conference whom are poor, readily pay The foundation of the service and the Christian Health for medicines from unlicensed delivery system; this includes Association of Kenya provide providers and this can have both demand creation (health about 65% of healthcare services detrimental consequences to promotion services) and specified in the country; together, the FBOs their health. Expenditure trends supply services that are most provide services in 17 referral still show that Kenyans pay for effectively delivered at the facilities, 59 mid-level hospitals, medications out-of-pocket. This community level. In the essential 133 clinics, and 657 dispenseries iii. illustrates that there is a willingness package, all non-facility based The private sector, which includes to pay for healthcare but there is health and related services are for profit organizations and NGOs, poor regulation in the sector to classified as community services also runs a number of health ensure that the services and drugs – not only the interventions facilities in Kenya and these range offered are of good quality vi. provided through the Community from high level hospitals to low- Health Strategy as defined in the cost health centres.. National Health Sector Strategic Health Financing Plan II (NHSSP II). Health System Capacity to Healthcare is financed from Deliver Care various sectors; these include Primary care level government, external donors, the As the Kenyan population private sector and out of pocket The first physical level of the continues to grow, there is also payments. By 2014, the proportion health system, comprising all an increasing pressure to create of out-of-pocket payments (OOP) dispensaries, health centres, and an integrated infrastructure to from individuals made up 36.7 maternity / nursing homes in the meet the growing demand on its % of healthcare expenditure country. This is the 1st level care health system. Large disparities followed by external donors at level, where most clients’ health exist within Kenya’s health system, 34.5% and the government took needs should be addressed. and this is due to the influence up 28.8% of healthcare costs vii. of underlying socio-economic, It is estimated that most of the County level gender, and geographical OOP were to private healthcare disparities iv. The reported ratio of providers viii. The burden of The first level hospitals, whose doctors and nurses is 0.2 and 0.9 healthcare costs in Kenya has services complement the primary per 1000 population respectively. devastating consequences

care level to allow for a more This impacts the quality of care for poorhouseholds, and this comprehensive package of close patients receive - especially by is also linked to the issue of to client services. those who are poor. More access. Although services pressing is the uneven distribution may be provided at no cost of staff between urban and rural in government facilities, National level areas. According to the Kenya geographical constraints for Health System Assessment those in rural areas means that The tertiary level hospitals, whose “rural dispensaries have 20 health facilities may be hard services are highly specialized and percent fill rates of their nursing to reach and they would incur complete the set of care available establishments, while district travel costs seeking healthcare. to persons in Kenya. hospitals have 120 percent fill This means that underserved

iii U.S. President’s Emergency Plan for AIDS Relief (2012). A Firm Foundation: The PEPFAR Consultation on the Role of Faith- based Organizations in Sustaining Community and Country Leadership in the Response to HIV/AIDS. Washington: U.S. Department of State, iv Healthy Action, 2011, v Kenya Health System Assessment: 34, vi Kenya Health System Assessment 2010; Private Sector for Innovation for Health, 2014, vii Private Sector for Innovation for Health, 2014, viii Private Sector for Innovation for Health, 2014 kenya translational research | 7

rural populations need to weigh the informal and uninsured new constitutional framework. the cost of receiving healthcare workforce in Kenya represents Moreover, the newly decentralized against the cost of transport, and around 83% of the population. system has given the Ministry of the time and expense spent away This population actively accesses Health (MOH) some autonomy from their livelihoods. Because the private sector for healthcare over service delivery to country the health system does not have for a variety of reasons, such ministries. the capacity to provide care to all as the perceived quality of Kenyan citizens most people use care provided by the private private healthcare providers to sector versus the public sector. purchase medicines ix. In addition, many specialized services like diagnostics or Kenya’s ongoing health insurance oncology treatment, are not scheme is the National Health available in the public sector Insurance Fund (NHIF), which which forces patients to access the was initially designed to serve private sector for treatment. employees in government and in the private sector earning Ksh Policy Environment 1000+, when it was introduced in 1966. A major challenge in the The policy environment as it scheme has been the integration relates to healthcare in Kenya of the expanding informal sector has multiple actors who are also and inclusion of the poorx. responsible for implementation; Although 40% of Kenyans live these partners include in poverty, most still purchase government agencies and non- healthcare in the private sector governmental organizations and this means that accessing (NGOs). These collaborations are healthcare for the poor is a major focused mainly on major disease The Public Private Partnership factor keeping them poor: “38% areas such as HIV, TB care and Act of 2009, passed by the of sick Kenyans did not seek health malaria ranging from vaccines and Kenyan Ministry of Finance and care because they lacked money health programming. implemented by the Ministry of while another third resorted to Health, regulates the authority self-medication; 15.3% of those of the government to create lacking money run into debts or The six objectives of the Kenyan partnerships with private health sell personal assets to offset health Health Policy Framework (1994-2010) explicitly state that sector organisations, or its ability care expenses xi”. PSP4H calls this to contract with private sector the “poverty penalty”. However, there is a need to collaborate organization(s) to deliver services the point that a large segment between various actors and the that advance public sector goals xii. of the Kenyan population is document further endorses the However, there are various barriers willing to pay out-of-pocket for establishment of its own Kenya within the enabling environment private healthcare is an important Health Sector Wide Approach that still exist, such as a uncertainty one, because it contradicts the (KHSWAp). This outlines the over the role of the private health “conventional wisdom [that] understanding between different sector in advancing national health accepts that the primary reason stakeholders providing healthcare priorities; burdensome regulatory that low income (aka working within Kenya’s health system. processes; weak enforcement poor) Kenyans are underserved Through the devolution that of regulations and standards; by healthcare providers is that took place in 2010, subsequent and limited incentives for private they cannot pay for care”. Instead, policies, namely The Kenya providers to serve the working according to research conducted Health Policy 2012 – 2030, poor and alleviate the burden on by the Private Sector Innovation have been developed to guide the public health care sector xiii. Programme for Health (PSP4H), partnerships between the state an initiative funded by DFID, and external actors within the

ix Private Sector for Innovation for Health, 2014, x Mathauer et al., 2008 as cited in Muiya and Kamau, 2013:3, xi Health Action, 2011:14, xii Private Sector Innovation Programme for Health. 2014. Private Provider Challenges. Series No. 10, xiii Private Sector Innovation Programme for Health. 2014. Private Provider Challenges. Series No. 10, 3 Objectives and Methodology

The objectives of this research will be

Understanding the METHODOLOGY Data collection replicability and scalability of high impact private sector To better understand the The main method used in this business models for low-cost relationships and successful research were case studies; cases primary care, developed integration of high impact in this instance are organizations and implemented in Kenya, private sector business models that have been identified from an within the South African for low-cost primary care within initial scoping exercise and that healthcare landscape. the Kenyan health system have used one of the financing landscape, the Bertha Centre team mechanisms described below to synthesised data gathered during deliver high impact primary care Determining illustrative literature reviews as well as key in Kenya. Organizations were models of where these interviews conducted during a selected to represent not only a market mechanisms have research visit to Nairobi, Kenya in variety of financing mechanisms been successful within the June 2015. Follow-up interviews but also rural, peri-urban, and Kenyan environment and with South African stakeholders urban areas. Through these lessons learned. were conducted to determine the cases we gained a deeper translatability of Kenyan models understanding of the model- Recognizing the enabling as well as to understand the structure, the implementing and inhibiting factors in the current South African primary care organization, the implementation Kenyan environment that landscape and ability to learn from journey and the barriers have impacted the success and implement lessons learned experienced. of these business models. from Kenya. Expert interviews were conducted Ascertaining the Key stakeholders interviewed to supplement the case study translatability of the included governmental officials, research performed during onsite innovative Kenyan business health care workers, and members visits. These interviews provided models to the South African of third-party organizations. an intersectional analysis of the health care environment In addition to the in-person appropriateness and applicability and developing interviews, which were conducted of these models in the Kenyan recommendations for local over a period of five days, the context, so as to identify these policy makers. Bertha Centre was also able to features in our local South African conduct site visits to various context (see Interview Schedule private primary care clinics. The below and Interview Guide in triangulation of data collected Appendix 1). through the interviews conducted with key stakeholders within the The literature reviewed for this Kenyan health care system assisted research identified gaps in South in synthesising several key findings. Africa’s health sector where these high impact models would be appropriate. Finally, the research findings were then translated to the South African health system context and recommendations for local policy makers were developed. kenya translational research | 9

INTERVIEWEE ORGANIZATIONS CAPACITY

Caroline Simumba Africa Capacity Alliance Expert

Ron Ashkin PSP4H Expert

Moka Lantum 2020MicroClinic Initiative Incentivization

Steven Mwandawiro 2020MicroClinic Initiative Incentivization

Rachel Waireri – Onyango GE Healthcare Kenya Expert

Liza Kimbo Viva Afya Cross-Subsidization

Alie Eleveld SWAP Franchising

Manya Dotson Jhpiego Expert

Eric Buch University of Pretoria Expert

Ashraf Grimwood Kheth’Impilo Expert

Ernest Darkho BroadReach Healthcare Expert

3.1 Adaptation Framework

The framework is a valuable them with agro-credits would not The Adaptation tool that will help to focus translate perfectly to the South Framework, as developed efforts on isolating the active African health care system, but ingredient that makes a the idea could be used in another by the Centre for Health particular innovation, or in this context, such as to incentives Market Innovations, case, innovative business model, within the chronic disease realm. successful and which in itself is served as the lens replicable on a cross-boundary Use of the Adaptation Framework basis. is especially relevant when through which the recognizing those innovative research, examination of Identification of an active business models or market ingredient renders it free of mechanisms that have business models, and the contextual constraints, and overarching implications for analysis of findings was enables stakeholders to apply policy-makers. Identification of the solution to different models. an active ingredient that has a conducted. This is particularly helpful when high probability for impactful considering replicability and replicability is likely to spur policy scalability of innovative business or regulation changes in order to models for the South African implement new approaches for health care landscape. For access to primary health within the example, Kenyan childhood private and public sectors. immunization programs that incentivize parents by awarding 3.2 Business Models and Applicable Examples

Franchising The Safe Water and AIDS Project The social impact envisaged (SWAP) in Kenya is an illustration by SWAP is developing Franchising, as it is traditionally of how this model works. The families and communities by known, is a business model NGO establishes business empowering women who are guided by a legal and contractual centers, called Jamii Centers, predominantly affected by HIV/ agreement whereby one firm or that train women in selling Aids and have very little income party pays the other for the rights water purification and other opportunities. SWAP works with to sell their products and use health related products to their community members who are their branding and trademarks communities. Women trained widows, government employed for a set period of time xiv. Social by SWAP are easily identifiable community health workers and franchising is a model guided through their unique branding women from HIV support groups. by the principles of franchising and trademark. SWAP works These groups of women are often but these are directed toward to deliver hygiene education subjected to stigma and poverty. improving and addressing and sanitation services to Therefore, the focus on them as societal challenges. Within rural communities and it does key health promoters helps to healthcare, social franchising this through a three-pronged raise their economic status which has been used as a scaling approach that fundamentally in turn has a positive impact mechanism to accelerate impact. seeks improve health outcomes upon their health outcomes and Social franchising in the context of through improved hygiene that of their families. SWAP also healthcare is defined as: practices and also empower reaches out to schools and clinics communities from low-socio in the surrounding areas to offer “A network of private sector economic settings: products and training in better healthcare providers with the hygiene practices. intention of providing health that • Research on sanitation are linked through agreements products use and monitoring Women recruited are trained to to provide socially beneficial be Community Health Promoters health services under a common • Procurement and selling (CHP), and their training includes franchise brand. A ‘franchisor’ products to communities marketing skills, business skills, (typically a non-profit) manages hygiene, and use of various the brand and oversees the • Training and empowering products meant to promote administration of the program” women from communities who health. Following their completed (http://www.sf4health.org/). are do door-to-door sales and training, they are given the training on the use of these products on credit to sell and products. once they have sold their stock

The past years have been dynamic and turbulent years of starting, testing, evaluating, adjusting, scaling up and now professionalizing and commercializing. SWAP with its wealth of experience and diversified skills is now at a point of outsourcing its activities, offering consulting services, training, research and lab activities for other partners. SWAP aims in the future to become self-reliant and less donor dependent by increasing revenue from sales of health and hygiene products while continuing to address public health concerns.

Alie Eleveld (In 2014 Annual Report)

xiv Beck, Deelder and Miller, 2010. Franchising in Frontier Markets: What’s Working,What’s Not, and Why. Dalberg Global Development Advisors Innovators. kenya translational research | 11

they reconcile their debt and take home their 10% profit from the sales. The point of access for SWAP into communities is through Jemii Centers located in rural areas, which are run by professionals from each respective community. This is where the CHPs come to collect new stock and return the profits made from products. The Jemii Centers are also hubs for training and support, and also for the selling of products for surrounding households. SWAP has lab facilities that test various products to ensure efficacy and quality for the products that reach communities. This testing process includes feedback from the CHPs who are directly reaching their individual community, and this information is triangulated in order to procure products that are in demand and

are successfully improving health Bev Meldrum credit: Photographers outcomes. that keeps SWAP relevant and in introduces a power dynamic that, Arguably, the active ingredient tune with the community’s needs to some, is unethical. However, the which animates SWAP is the and, most importantly, disease conversation has now shifted to strong relationship that the trends. Going into communities, exploring where this model can be community health promoters SWAP engaged extensively with used in an effective and equitable forge both with SWAP itself various stakeholders such as manner. So far, effective use of as well as with their fellow health ministries and chiefs which incentivization to encourage community members. One of the allows them to be part of village positive behaviour changes has challenges the organization has communities and the organizations been applied in the areas of faced is competition from other deploy community members into vaccinations and in delivery of local vendors who sell the same Jamii centers who understand the family planning and prenatal care. products, sometimes at a lowered people and the context. rate. However, CHPs have been The benefit of this approach has able to sustain their trade because Incentivization been that in certain cases, those of the time they spent training improved health outcomes which people to use their products and were motivated by incentives According to Dow and White this has therefore ensured that have themselves been motivators (2013) incentivization in healthcare CHPs have gained trust within their for changed health behaviours has been surrounded by some communities. more so than the actual incentives controversy from an ethical offered. For example, a mother’s standpoint, as it has been claimed Another key element contributing attitude and approach to antenatal to undermine people’s agency to SWAPs success within care changes significantly and ability to make independent communities is that product when she has a healthier child. decisions. Moreover, the use of placement is a result of an Long standing examples of programmes involving incentives iterative and empirical process incentivization programmes 3.2 Business Models and Applicable Examples... continued

include Marie Stopes International (MSI), which has used this approach in a number of developing countries, including Kenya, to encourage better family planning and use of antenatal services.

An example of this model is the barcode vaccination card developed by Dr Benson Wamalwa from the University of Nairobi. The barcoded vaccination card was designed to address a barrier to access which is not unique to Kenya, namely that rural mothers are unable to travel easily to the nearest clinics to receive necessary immunizations both for themselves and their children. The remoteness of their home communities, the cost and time on immunization campaigns to save the discount via a layaway associated with travel, and the or equipping and transporting account. This is an empowering expense of the immunizations health workers to remote mechanism, as it enables users and vaccines themselves and hard-to-access regions is to establish savings that can then compounds the difficulty in shifted from the public health be leveraged in a variety of ways. accessing care and results in sector. The innovation of the For example, the funds can be immunizations drop-outs as well card is that it specifically targets used for out-of-pocket expenses as pervasive non-vaccination. Dr families, pregnant women, and/ related to transportation or other Wamalwa therefore developed or caregivers who live on remote healthcare related needs, such as the barcoded vaccination card to smallholdings. the childbirth process itself. specifically address these critical issues. The impact of successful Once registered at first contact This is a creative and innovative implementation would be the with a primary health facility, the solution that has as its active appreciable improvement of the child’s caregiver or the pregnant ingredient the integration of the survival rates of children <5 years woman is issued with a card healthcare delivery function with by tackling vaccine preventable equipped with a unique barcode rural livelihood practices. health issues and diseases. that enables redemption of agrocredits. The card is pre- By providing an incentive to The card has been carefully loaded with agrocredits each rural mothers to travel to health designed to appeal to a time that the pregnant woman/ clinics, the program ensures broad spectrum of community child attends either an antenatal that expectant women access stakeholders, with the effect care appointment or a vaccination necessary antenatal care and that use of this innovation will clinic. The card is then redeemable that children are no longer lost be proactive and will lead to in the form of price discounts to unregistered home births a grassroots movement to from a local Agrovet shop. This while encouraging the mothers/ immunize. This self-mobilization enables families to “purchase” caregivers vaccinate them means that the burden for essential farm inputs for their against preventable diseases. By manpower and resources spent smallholdings or it allows them doing so, the household is then kenya translational research | 13

able to purchase vital farming urban environments where locally based community health and equipment needs for their there is limited access to quality workers, Viva Afya is able to build smallholdings at a discount, care. Expensive resources and bridges between communities positively impacting their harvest equipment are concentrated at and clinics through organized and their income. The solution is the hub or anchor clinics, which group meetings, community also sustainable, as the Agrovet are in turn supported by the outreach, and promotional stores attracts clientèle thereby referrals generated from the activities. Through these efforts, boosting their social capital as smaller spoke or satellite clinics; the organization is able to educate well as their margins, and the the this model also promotes internal its target market regarding what families impacted are able to grow and supply chain efficiencies. This high quality health services are their personal savings in a journey model has ensured that affordable available, what preventative towards financial empowerment. primary health care and specialist measures are appropriate, when consulting services are provided they should be seeking care, etc. underserved populations. Since 2014, Viva Afya’s community Cross-subsidization outreach has reached over 21,000 Viva Afya’s success means people. Cross subsidization in health that it is now operating the is a financing mechanism that largest network of outpatient This type of effective targeted fundamentally seeks to equalize clinics in Nairobi’s low-income community outreach also helps risk xv. In practical terms, this areas. The clinics are staffed to address the pernicious impact means that in every method of by appropriately qualified and of the unlicensed health facilities pooling funds, such as medical licensed healthcare professionals, that are hugely popular in Nairobi. schemes, community health including clinical officers, nursing These types of facilities offer users schemes, or National Health staff, and pharmaceutical and low quality primary health care Insurance, resources are placed lab technologists. Each clinic is at very low prices; services are according to need despite how managed by a clinical officer, who offered by unqualified providers much members contribute. In is then incentivised to grow their and counterfeit pharmaceutical South Africa, the distribution of patient base while maintaining products are widely distributed. resources in the private sector is affordability, quality of care, and This increases the health risks to inequitable; thus, those who need ease of access for key populations. the communities in which the Viva healthcare services cannot access Afya clinics are located, and it them. In a country that has a Viva Afya clinics are conveniently increases the financial and social Gini-coefficient of 0.65 and visible located for local residents; for burden on families and patients inequality, cross-subsidization example, per CEO Liza Kembo, attempting to mitigate the would decrease disease burden close to 100% of health service effects of seeking care from such because often-times those seekers are able to walk to the unlicensed facilities as well as on who are wealthier are healthier; clinics from their homes. In the public health sector that must therefore, their funds can be used addition, all clinics are open at then treat those impacted by such to treat those who are poor and least 12 hours every day, with low quality, harmful care. sickly xvi. one open 24 hours per day. This means that people are Viva Afya, a healthcare enterprise able to access care in a manner providing high-quality, that is convenient to their own comprehensive, and low-cost employment schedules. Since primary healthcare services in 2014, Viva Afya has provided Nairobi’s low-income areas, high quality, low cost health care is an example of an effective services to 59,000 clients. cross-subsidization model. The organization functions as a hub Viva Afya’s active ingredient and spoke model, whereby the is the utilization of community use of anchor and satellite clinics outreach to better educate enable the provision of health the residents living in the services to wider populations communities in which each of low- and middle-income clinic is located. By employing groups living within poorly served

xv Ataguba & Akazali, 2010. Healthcare financing in South Africa: Moving towards universal coverage. CME, Volume 28 (2), xvi Ataguba & Akazali, 2010. Healthcare financing in South Africa: Moving towards universal coverage. CME, Volume 28 (2). 4 Key Findings

The Kenyan healthcare sector is a vibrant one characterized by diverse and innovative business models that are able to take advantage of the lower middle class, or working poor, segment of the population.

the perception that the services accessed in the private healthcare sector are of a far superior quality and are more convenient than those found in the public sector.

In a recent survey conducted by PSP4H of 435 working poor households in peri-urban areas of Nairobi, only 24.9% of respondents indicated that financial constraints contributed to failure to seek necessary healthcare services xviii. Proponents of innovative healthcare business models, such as those highlighted in this report, have recognized that offering the working poor better value for money in the This slice of the healthcare Health Service Diversity healthcare services available market totals more than 20 to them will allow access to a potentially huge market. million people xvii. The private Diversity of affordable private To appropriately implement sector already comfortably sector service offerings within successful low-cost, high quality accesses the upper and middle/ Kenya allows organizations and delivery models of care, PSP4H middle-low tiers of health service providers to leverage the advocates “match[ing] pricing to consumers, and is willing to buying power of the informally existing spending patterns, which leave the healthcare needs of employed or jua kali, a sector are closely tied to daily income, the absolute poor to the public that comprises 83% of Kenya’s instead of requiring new spending sector. Therefore, understanding population. This population behaviours xix”. The key, therefore, how the working poor access purchases their healthcare out- as argued by Ron Ashkin from healthcare, the services available of-pocket at a time when they PSP4H, is to market to the to them, the attitudes around need it rather than devoting organized informal sector on an health seeking behaviour, and a portion of their disposable aggregate level. the complex socio-economic, income towards purchasing gender, and cultural implications an intangible such as health The quality, cost, and physical is extremely valuable. insurance. Private providers have accessibility of public health a high interest in creating and services available often-times Following is a brief description of marketing services to the working negatively impact the decision each of the findings derived from poor, since this segment of the to seek care from these facilities. data collection and interviews with population has demonstrably An additional factor that makes key stakeholders. proven its willingness to demand seeking health services more high quality health services and attractive in the private versus the willingness to pay for these the public sector is not only the services and products. This diversity of healthcare models willingness to pay is linked to

xvii Private Sector Innovation Programme for Health, 2014. What we Learned about Private Health Sector’s Ability to Serve the Working Poor in Kenya. Series No. 2, xviii Private Sector Innovation Programme for Health, 2014. The Myth that “The Poor Can’t Pay”: Health Spending Behaviour among Low income Consumers in Kenya. Series No. 15, xix Private Sector Innovation Programme for Health, 2014. The Myth that “The Poor Can’t Pay”: Health Spending Behaviour among Low income Consumers in Kenya. Series No. 15 kenya translational research | 15

but also the diversity of actual Many of the service delivery Kenyans have a fine-tuned sense services being offered. The public mechanisms discussed refer into of themselves as consumers health sector focuses its efforts the public sector, and do not view of a product, i.e. healthcare. on HIV/AIDS, malaria, and child themselves as in competition They are able to recognize and maternal health services while with the public sector but rather and take advantage of the fact neglecting non-communicable as fulfilling a complementary role that healthcare is a service and diseases, dentistry, and mental which then uses the necessary commodity to be shopped for. health, for example xx. These channels to ensure patients return Kenyans scan the healthcare gaps in provision allow private back to the public health referral offerings and services available, healthcare providers to offer chain as appropriate. and make informed choices targeted services to the working based on what they are willing poor. These services might be to pay, how far they are willing to Healthcare Consumption seen as balancing the public travel, etc. In addition, Kenyans are Attitudes service offerings available; sophisticated users of the internet; therefore, the private models that in 2015, 22.3 million internet users target low-income groups fill the As active consumers of or 54.8% of the population had healthcare, the working poor disparities left by the public sector. ready access these services xxi. The public sector is operating in Kenya make strategic The very high penetration rate of under constrained resource needs decisions whether it is deciding the internet means that almost all and maintains a strong focus on to seek care from unregulated populations have easy access to national health priority issues, pharmacies or whether it is in research about health conditions, and this leaves others services accessing care from a licensed, services, etc. and are therefore and needs under-supplied. qualified private provider. more likely to make discerning choices based on their healthcare needs and willingness to spend. Overall, patients value efficiency and consideration of their time, which are areas that organizations such as 2020MicroClinic Initiative and VivaAfya focus on.

Cultural beliefs play a significant role in influencing healthcare consumption attitudes. Widespread education about the importance of preventative health measures as well as the pursuit of healthy lifestyles does not exist xxii. This contributes to the “poverty penalty”, which means that consumers do not access necessary health services in a timely manner because they either a) choose to self-medicate; b) seek care from informal providers; or c) feel that they cannot afford appropriate care. Therefore, once they finally do seek treatment it

xx Private Sector Innovation Programme for Health, 2014. A Formative Survey of the Private Health Sector in the Context of the Working Poor, xxi Communications Authority of Kenya, 2015, xxii Private Sector Innovation Programme for Health, 2014. Private Provider Challenges. Series No. 10 4 key findings... continued

can be very expensive, or in some • Shorter waiting times day. This means that people are cases, may even be too late to be able to access care in a manner effective. Educating consumers • Availability of staff, particularly that is convenient to their own about healthcare ensures that they doctors employment schedules. understand the importance of seeking care and the concurrent • Availability of equipment and Challenges Facing the importance of compliance with supplies Private Sector follow-up treatment. Innovations like the barcode incentivization These reasons clarify that the The private sector is able to be card mentioned above, help working poor are willing to pay for extremely nimble and responsive to encourage access to care. quality patient care but that they to the needs identified by its By providing an incentive to also want value for their money. target population, in this case, rural mothers to travel to health This is arguably why a business Kenya’s working poor. However, clinics, the program ensures model such as Viva Afya has Kenyan private healthcare that expectant women access been so successful, because its providers face constraints in necessary antenatal care and make-up addresses each of the market penetration that prevent that children are no longer lost preferences listed above. Viva Afya them from fully engaging with to unregistered home births clinics are conveniently located potential consumers in the lower- while encouraging the mothers/ for local residents; for example, middle class and working poor caregivers vaccinate them against per CEO Liza Kembo, close to segments of society. Barriers preventable diseases. 100% of health service seekers to access include operational are able to walk to the clinics from and regulatory concerns, as well As discussed previously, their homes. In addition, all clinics as challenges around cost and Kenyans defined as members are open at least 12 hours every competition. of the “working poor” have day, with one open 24 hours per demonstrated their willingness and ability to pay for provide healthcare services within the private sector. A study conducted by PSP4H across 12 Kenyan counties included focus group discussions with 518 participants. This study revealed that the reasons the working poor chose to access the private sector include xxiii:

• Perceived quality of care and services

• Confidentiality

• Convenience (longer opening hours)

• Easy access to the facility

• Positive provider attitude and behaviours

• Availability of specialized services

xxiii Private Sector Innovation Programme for Health, 2014. What we Learned about Private Health Sector’s Ability to Serve the Working Poor in Kenya. Series No. 2 kenya translational research | 17

Operational and healthcare professionals are Regulatory Opportunities the number one expense for for Improvement private providers while drugs are the second most expensive • The Kenyan national Ministry line item xxv. of Health has not clearly spelled out what kind of role • Private healthcare providers the private sector can play in might have the entrepreneurial provision of services around spirit necessary to pursue national health priorities business in this sector, xxiv. Without formulating a but often-times they lack clear policy framework for the business and financial collaboration, the private sector management skills to ensure lacks the necessary clarity success xxvi. to align activities to national health priorities. • Strategic market planning is a major concern, especially with • In common with many a high risk group such as the countries, national policies working poor. Moreover, the and regulations are ability to develop a compelling burdensome and costly to and strongly focused market comply with. Processes are not plan is hampered not only by streamlined, are confusing, this type of high risk group and functionalities are shared but also by the types of areas across departments, creating target populations reside in. a time-consuming and When underserved areas are exhausting practice of ensuring lacking necessities such as regulatory compliance. running water and electricity, are considered unsafe, and • Kenya does not actively are inhabited by transient incentivise the private residents, it is difficult to retain sector to serve the working a solid customer base and it poor. Without appropriate is difficult to recruit qualified concerns, as well as the challenges encouragement, the private personnel whom are willing to around cost and competition, are sector will not leverage its work under such conditions. the breakdowns in information resources to help shift the and knowledge sharing. The burden of ensuring national • Drug regulation and availability private health sector struggles health priorities are realized remains a problem despite to be included in MoH policy while also offering targeted regulation policies, as Kenyan and strategy creation, while in specialized services. citizens, especially those return “the MoH still struggles to whom are poor, readily pay motivate the private health sector for medicines from unlicensed to regularly report its activities Cost and Competition providers and this can have to the MoH health management detrimental consequences information system” which means • Business start-up costs, which to their health. More broadly, that decision-making on both include licensing, personnel unlicensed and/or informal sides is not made by including training, medical and healthcare providers create all stakeholder groups xxvii. Finally, capital equipment, property real competition for private updates on regulations are not purchase or rental fees, and healthcare providers. timely, dissemination of standards drug supplies, can prove to is not widely done, and few clinical be prohibitive. According Compounding the issues of training opportunities exist for to PSP4H, labour costs for operational and regulatory private providers xxviii.

xxiv Private Sector Innovation Programme for Health, 2014. Private Provider Challenges. Series No. 10, xxv Private Sector Innovation Programme for Health, 2014. Private Provider Challenges. Series No. 10, xxvi Private Sector Innovation Programme for Health, 2014. Private Provider Challenges. Series No. 10, 4 key findings... continued

Presence of NGO’s as a are analogous to the stokvel to chamas in their villages even Challenge for Social clubs found in South Africa. These when they move into urban areas Enterprises societies, originally founded to such as Nairobi. One interviewee combat poverty and run in an noted that the reason some Externally funded healthcare informal context, have become Kenyans are able to access private dominates the Kenyan powerful organizations that healthcare are due to chamas, healthcare landscape, where account for a significant portion such as in cases where community services provided by faith based of the Kenyan GDP. Community members pull together funds for a organizations, for example, organizations such as these have neighbour or acquaintance having comprise 65% of healthcare implications for the healthcare an operation or needing to access provision xxix; and, where 26% sector, particularly regarding expensive services. of Kenya’s health expenditure insurance because developing is donor funded xxx. Donors, a relationship with SACCO Chamas are community groups therefore, function as a real form leadership ensures access to the founded on what Kenyans call of competition for private health potentially thousands of SACCO “Harambe” culture, the equivalent sector providers. Donor subsidies, members. of Ubuntu in South Africa; the for infrastructure, drugs, and distinction however, is that in medical equipment and testing SWAP has been able to leverage Kenya this is shown through services, support the public health the power of these types of proactive responses to the needs sector while ensuring that private organizations. A number of the of fellow community members. providers are unable to compete community health promoters Chamas are a pooling mechanism within the marketplace xxxi. were endorsed through their and funds contributed by its village health committees, members are used to pay for Working within environments that chamas, and/or support groups. a variety of things, these range are heavily populated with NGO’s These are key features of village from paying for university fees to often-times makes it difficult to health systems that offer support medical procedures. Surprisingly, sell products. One the major and funding for members when these have survived without challenges Community Health seeking healthcare. Organizing governmental regulations, as Promoters from SWAP noted is of this nature is a not only seen existing traditional systems and that people were not willing to in rural spaces, as people from cultural norms still drive the purchase items they receive free these communities still contribute success of these groups. By from NGOs. The downside to this is that they noticed the products were not used properly and to some extent could be harmful because of this. Furthermore, this is not sustainable as a mechanism of maintaining health and creates unrealistic expectations in vulnerable communities, especially if a donor subsequently pulls out.

Proactive Culture

Kenyan society is marked by strong reliance on and support of social groups like Savings and Credit Co-Operations (SACCOs) and “chamas”, which

xxvii Private Sector Innovation Programme for Health, 2014. Private Provider Challenges. Series No. 10, xxviii Private Sector Innovation Programme for Health, 2014. Private Provider Challenges. Series No. 10 xxix U.S. President’s Emergency Plan for AIDS Relief (2012). A Firm Foundation: The PEPFAR Consultation on the Role of Faith- based Organizations in Sustaining Community and Country Leadership in the Response to HIV/AIDS. Washington: U.S. Department of State, xxx Kenya National Health Accounts 2012/13, xxxi Private Sector Innovation Programme for Health, 2014. Private Provider Challenges. Series No. 10 kenya translational research | 19

developing a low-cost model that will tap into the organization occurring through these informal networks, private providers will be able to access huge pools of potential healthcare consumers xxxii. An example of a health insurer that is attempting to do this is Afya Poa, which is a micro- insurance product developed by Jawabu Empowerment. One of the strategies employed by Afya Poa was to leverage the power of the chamas and to sell insurance policies through these community groups xxxiii. Barriers to its success include regulatory issues and negotiation with chamas and other jua kali community groups.

Shifting Gender Norms

Barriers to healthcare access do not only include financial considerations or remoteness of to provide funds, can have a a key consideration for SWAP. location, but also include issues significant impact the ability of Thus, when recruiting community xxxvi. such as delayed treatment related women to access healthcare health promoters, their husbands to the status of women xxxiv or During time spent with SWAP, and partners were also invited general financial decision making we interviewing female CHPs to observe the process and to processes within individual on how their work affected their celebrate with the women when households. As a fairly traditional relationships with their spouses/ their training was complete. A society, the head of household – partners. They noted that there number of women who were usually a male – generally makes was an appreciable shift in their married had some assistance on major financial decisions for lifestyles and relationships because weekends from their children and Kenyan families. Therefore, men they were contributing to the husbands when doing their round “as the financial providers and household and alleviating pressure of sales, making this a family affair. custodians of the household, on their husbands. Collaborative [make] decisions that require[d] a decision-making within the significant amount of money xxxv”. household was also mentioned as This type of dynamic can even a different and pleasant result of extend to health seeking behaviour the women’s financial contributions itself, and therefore Kenyan to their homes. Gender norms that men, through their willingness lead to domestic violence were

xxxii Private Sector Innovation Programme for Health, 2014. A Comparative Analysis of Health Markets and Private For-Profit, Pro-Poor Interventions in East Africa, xxxiii Private Sector Innovation Programme for Health, 2014. A Comparative Analysis of Health Markets and Private For-Profit, Pro-Poor Interventions in East Africa, xxxiv Private Sector Innovation Programme for Health, 2014. What we Learned about Private Health Sector’s Ability to Serve the Working Poor in Kenya. Series No. 2, xxxv Private Sector Innovation Programme for Health, 2014. A Formative Survey of the Private Health Sector in the Context of the Working Poor, xxxvi Fotso JC, and Mukiira C. 2011. Perceived Quality of and Access to Care Among Poor Urban Women in Kenya and their Utilization of Delivery Care: Harnessing the Potential of Private Clinics? Health Policy and Planning 27[6]:505-15 5 Recommendations for South Africa

Southern African patient care, responsiveness to African population xxxix. These system constraints, and sensitivity tools include financing policy countries have to management capacity interventions, such as subsidies, limited resources and constraints xxxvii. Furthermore, which can have significant collaboration and integration impacts upon health market governments must between government and dynamics xl. If not kept in balance, the private sector can have these interventions can stifle prioritize activities and positive repercussions in other competition with the private responsibilities in all areas of health care delivery healthcare sector. Therefore, to due to increased dialogue and effectively engage the private areas, including the information exchange, and can sector, it is important to ensure healthcare system. serve as a catalyst for further cross- the free flow of information sectoral engagement xxxviii. across the health system so that private actors can align Private and third-sector Governments across sub- their activities with public organizations can supplement the Saharan Africa may struggle to health goals. Transparency will resource needs and narrow the fulfil their mandate to effectively also enable the government demand gap that exists within the deliver health care services to to involve the private sector in healthcare sector. their populations unless they developing and implementing practice some minimal level policies and regulations, while From the learnings within the of engagement with private also taking advantage of “strategic Kenyan context, the following healthcare service providers. opportunities to harness private recommendations have bearing Partnering with the private sector, sector resources and expertise xli”. on the South African context: in policy setting, planning and implementation of health care Promote Burden Shifting Increase Partnership with delivery would lessen the burden within Healthcare Sectors the Private Sector on governments while opening up the possibility to access In the public sector there is a effective and innovative models Achieving efficient, effective, and substantial shortage of health of patient care delivery. As further equitable access to healthcare, workers especially in rural areas. discussed below, partnership that is responsive to all citizens, The ratio of physicians per 10 between the sectors can take requires the unlocking of dormant 000 population is 8 and there the form of shifting the burden resources present in the private are 5.1 nurses per 10 000 of care from the heavily utilized and third-sector organizations populations. The first obstacle public sector to the private sector; especially those that are already that has been identified is the of employing the private sector responsible for increasing issue of retention of health to train medical professionals; healthcare access. Collaboration professionals in poor, rural areas. or of actively working to change with these organisations can This shortage of healthcare consumers attitudes about enhance what government is professionals is providing South healthcare consumption. already able to provide and Africa the opportunity to explore would ensure better access and other cadres of health workers The South African Ministry of continuity of care for those in and the greater involvement of Health, at both the national and need of health care services lay people in the delivery of care. at the provincial levels, is able especially looking forward to The lessons learned in this respect to draw on various policies and implementation of the National from Kenyan healthcare delivery regulations that will enable it to Health Insurance plan. The providers such as Viva Afya, which work towards achieving access, private sector organizations employs clinical officers versus affordability, and quality of health play a valuable role in fostering doctors in its clinics, are extremely services for the entire South innovation, competition, quality valuable. kenya translational research | 21

Finding alternative models to relationships with existing GP Mid-level providers and medical address this current reality is a referral networks. workers can play an essential role national imperative. Private health in health systems. The success sector engagement mechanisms Another example of burden of task-shifting as a systems such as down referral innovation shifting within the South African intervention with the integration and/or contracting out GP healthcare landscape is the of community health workers has services, particularly in the context Kheth’Impilo Pharmacist Assistant been successful in alleviating the of declining or stagnant external Project. South Africa currently congestion in the public health donor funding, presents a strong suffers from a skills gap within the sector. Another area where this opportunity to expand health public pharmacy sector as most has been effective is in allowing sector capacity to meet public qualified pharmacists choose to nurses to take on tasks traditionally needs. A model that addresses practice in the private sector. To ascribed to doctors such as ARV this need in an innovative fashion address this gap, Kheth’Impilo prescriptions and training them to is the BroadReach Healthcare GP initiated a pharmacist assistant prescribe treatments for primary Down Referral Model. training program through the care. utilization of external grants. The BroadReach Healthcare Candidates are recruited from GP Down Referral Model was marginalized communities and developed to address the need to placed in government facilities shift the burden of delivering HIV/ where they are trained to deliver AIDS treatment to stable patients a service from the first day of from the public to the private training. To date, more than 230 sector. Specifically initiated within post basic pharmacist assistants the North West province, the have been trained, and their BroadReach model funnels stable impact has had the result of patients into a private sector down reducing patient waiting times, referral program for provision improving quality of patient of routine care. This allows care, and overall reducing the public health facilities within the burden on the public pharmacy province to focus on managing facilities in which they are placed. complicated patients, non- A pharmacist completes studies compliant patients, and initiating after five years while a nurse new ART-eligible patients. Burden completes studies after four shifting in this manner fulfils a years. Through the Kheth’Impilo number of key goals, such as 1) program, a pharmacist assistant reducing the drain on the public can qualify in two years, resulting sector; 2) improving access to in a faster, more cost effective and treatment; and 3) enhancing efficient intervention as it allows patient outcomes. This is a unique each professional to operate at model of care, and it aligns with their maximum skill level. the stated goals and objectives of the National Health Insurance plan to enhance the quality of treatment within the primary healthcare sphere. Factors to success include development of a strong working relationship with the North West Department of Health, alignment with provincial and national health plans and policies, and maintaining close xxxvii Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa. World Bank, 2011, xxxviii Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa. World Bank, 2011, xxxix Private Sector Innovation Programme for Health, 2014. A Comparative Analysis of Health Markets and Private For-Profit, Pro-Poor Interventions in East Africa, xl Private Sector Innovation Programme for Health, 2014. A Comparative Analysis of Health Markets and Private For-Profit, Pro-Poor Interventions in East Africa, xli Private Sector Innovation Programme for Health, 2014. A Comparative Analysis of Health Markets and Private For-Profit, Pro-Poor Interventions in East Africa 5 recommendations for south africa... continued

Promote Skills Association of South Africa, the cadres of clinical associates in Development within the findings suggested that the 2008 as an attempt to deal with Private Sector as well private healthcare sector has two its critical shortage of medical as Training of Mid-Level possible avenues of participation workers. These clinical associates Providers within the provision of medical were envisioned as a means to education. Firstly, allowing the strengthen primary healthcare South Africa is currently suffering establishment and accreditation provision at a district level, by from a severe skills shortage of private medical colleges would allowing them to support over- across medical professions, and allow the training of a greater burdened doctors and reduce this shortage is exacerbated by number of medical doctors the need for costly referrals xlvi. the in-equal resource distribution at the least cost to the public; Clinical associates operate under across the private and public and secondly, encouraging the supervision of doctors, and are healthcare sectors as well as greater participation of private generalist rather than specialist between rural and urban areas xlii. hospitals and specialists in the providers. Challenges to this This shortage is of particular clinical training of South African programme include overly rapid concern given the approaching undergraduate students would implementation, which left the implementation of the proposed be a cost effective way in which public sector unable to support National Health Insurance plan. the private sector can contribute the influx of this new type of While currently in its pilot phase, to capacity training xliv. There medical xlvii expert. In addition, implementation of the NHI with are already examples that exist funding shortfalls, poor support its focus on primary healthcare that prove the efficacy of such for clinical associates placed in calls for even greater numbers an approach, i.e., Mediclinic rural or peri-urban areas, and lack of qualified medical professions South Africa has partnered with of posts within the public sector across all competencies. the University of Stellenbosch all contributed to negatively Therefore, the ability of the to provide opportunities where impact the sustainability of education system to meet this internal medicine students can the programme xlviii. Possible need has a direct impact upon complete a portion of their recommendations to address achieving the goals of the NHI. rotation at a Mediclinic facility xlv. this issue would be to partner with the private sector to cultivate South Africa currently has eight Viva Afya provides an excellent initiatives that would mirror those public medical schools, and example of how the use of clinical developed by Kheth’Impilo and there is a prohibition on private officers or associates meets an BroadReach Healthcare, i.e. using universities offering medical immediate clinical need within clinical associates to actively education and training; therefore, underserved populations. participate in down referral there is practical limitation on “the Mid-level providers, such as models to facilitate burden private sector’s ability to help lift clinical associates or physician shifting from the public health this burden, and leaves training in assistants, play an important sector. the public sector constrained by role in alleviating service limited funding and resources”xliii. burdens while also addressing In a 2015 study conducted by human resource shortages. Econex on behalf of the Hospital South Africa began training

xlii Econex, 2015. Identifying the Determinants of and Solutions to the Shortage of Doctors in South Africa: Is there a Role for the Private Sector in Medical Education?, xliii Econex, 2015. Identifying the Determinants of and Solutions to the Shortage of Doctors in South Africa: Is there a Role for the Private Sector in Medical Education?, xliv Econex, 2015. Identifying the Determinants of and Solutions to the Shortage of Doctors in South Africa: Is there a Role for the Private Sector in Medical Education?, xlv Econex, 2015. Identifying the Determinants of and Solutions to the Shortage of Doctors in South Africa: Is there a Role for the Private Sector in Medical Education?, xlvi Doherty, Conco, Couper, & Fonn, 2013. Developing a new mid-level health worker: lessons from South Africa’s experience with clinical associates, xlvii Doherty, Conco, Couper, & Fonn, 2013. Developing a new mid-level health worker: lessons from South Africa’s experience with clinical associates, xlviii Doherty, Conco, Couper, & Fonn, 2013. Developing a new mid-level health worker: lessons from South Africa’s experience with clinical associates kenya translational research | 23

service being purchased. Kenyans scan the health care offerings and services available, and make informed choices based on what they are willing to pay, how far they are willing to travel, etc. The very high penetration rate of the internet means that almost all populations have easy access to research about health conditions, services, etc.

Actively attempting to understand healthcare consumption attitudes would be invaluable in developing market interventions that would encourage broader use of the South African private healthcare Develop Healthcare Service The health system in Kenya is sector by the lower middle Market Plan to Meet Needs not as restrictive as in South class and the working poor. This of Various Income Classes Africa where those in who cannot would service the public health afford private healthcare are goals of the National Health Public health facilities are very completely relegated to the Insurance plan, by encouraging congested because the ratio public sector. Micro insurance burden shifting in the provision of patients to health workers is schemes for example have been of primary healthcare services. disproportional, thus they have a key financing mechanism Lessons learned from the Kenyan long waiting times and often that has allowed Kenyans in the healthcare landscape encourages times people miss work while middle to lower middle income the assumption that South African waiting to be attended to and group access to private care. health consumers likewise prefer health workers are stretched. Furthermore, those in the informal to access the private sector due Private health facilities do not sector can make the choice to to perceived quality of services, face these challenges but are access private healthcare even convenience, availability of not affordable for those who are though their income is irregular. specialized services, and shorter in low socio-economic settings. waiting times. However, shifting One of the noticeable trends the focus from healthcare as a in South Africa is a growing Healthcare Consumption public good to healthcare as middle class, defined as earners Attitudes a product that consumers can above R25 000 per person per be discerning in purchasing will xlix not occur unless there are more year . This group has steadily Kenyans have a fine-tuned sense options available to the working grown from 3.6 million to 7 of themselves as consumers l poor that would encourage them million since 1993. This growing of a product, i.e. healthcare. to pay for services within the group presents an opportunity They are able to recognize private sector versus simply taking for private healthcare providers and take advantage of the fact advantage of what is provided by which can develop and market that healthcare is a service and the public sector simply because service delivery to serve various commodity to be shopped that is the default option. income groups. for, versus what is arguably the traditional South African mindset Kenya has been filling this gap that healthcare is a benefit that with a competitive private sector. devolves to them rather than a

xlix Kotzé, du Toit, Khunou, & Steenekamp, 2013. The Emergent South African Middle Class, lKotzé, du Toit, Khunou, & Steenekamp, 2013. The Emergent South African Middle Class 6 CONCLUSION

South African policy makers can take advantage of the lessons learned from the Kenyan health care system, and its experiences with the private healthcare sector. By breaking down the siloes that exist within the sectors of health care delivery, an open dialogue can be created that will promote transparency, build trust, and ensure the recognition that across the sectors there exists similar agendas; focused on providing health care to all members of the national population.

Coordination of care would relieve the burden on a system that is suffering from severe capacity constraints, would provide support through leadership and mentoring to those health care providers and ultimately allow for the optimal delivery of patient- centered care. Learning from the lessons provided by the Kenyan healthcare system, it is arguable that private sector healthcare providers – whether Kenyan or South African – are ready to provide priority health services to underserved populations who have evidenced the willingness to pay for this care provision. However, this opportunity must be supported by policies and market conditions that will allow private healthcare providers to support the goals of the South African NHI plan. kenya translational research | 25

7 REFERENCES

1. Ataguba, J., & Akazali, J. (2010). 10. Private Sector Innovation Programme for Healthcare financing in South Africa: Health, 2014. A Formative Survey of the Moving towards universal coverage. CME, Private Health Sector in the Context of the Volume 28 (2). Working Poor

2. Beck, S., Deelder, W., & Miller, R. (2010). 11. Private Sector Innovation Programme for Franchising in Frontier Markets: What’s Health, 2014. A Comparative Analysis of Working,What’s Not, and Why. Dalberg Health Markets and Private For-Profit, Pro- Global Development Advisors Innovators. Poor Interventions in East Africa

3. William, D., & White, J. (2013). 12. Fotso JC, and Mukiira C. 2011. Perceived Incentivizing use of healthcare. United Quality of and Access to Care Among Nations Department of Economic and Poor Urban Women in Kenya and their Social Affairs, Expert Paper no. 2013/13. Utilization of Delivery Care: Harnessing the Potential of Private Clinics? Health Policy 4. World Bank. (2013, June 09). Retrieved and Planning 27[6]:505-15 from Worldbank.org: http://www. worldbank.org/en/country/kenya/overview 13. Healthy Partnerships: How Governments Can Engage the Private Sector to Improve 5. Dawad, S. and Veenstra, N. Comparative Health in Africa. World Bank, 2011 health systems research in a context of HIV/AIDS: lessons from a multi-country 14. Econex, 2015. Identifying the study in South Africa, Tanzania and Determinants of and Solutions to the Zambia. Health Research Policy and Shortage of Doctors in South Africa: Systems 2007, 5:13 Is there a Role for the Private Sector in Medical Education? 6. Private Sector Innovation Programme for Health. 2014. Private Provider Challenges. 15. Doherty, Conco, Couper, & Fonn, 2013. Series No. 10 Developing a new mid-level health worker: lessons from South Africa’s experience with 7. Beck, Deelder and Miller, 2010. clinical associates Franchising in Frontier Markets: What’s Working,What’s Not, and Why. Dalberg 16. Kotzé, du Toit, Khunou, & Steenekamp, Global Development Advisors Innovators 2013. The Emergent South African Middle Class 8. Private Sector Innovation Programme for Health, 2014. What we Learned about 17. U.S. President’s Emergency Plan for Private Health Sector’s Ability to Serve the AIDS Relief (2012). A Firm Foundation: Working Poor in Kenya. Series No. 2 The PEPFAR Consultation on the Role of Faith- based Organizations in Sustaining 9. Private Sector Innovation Programme for Community and Country Leadership in the Health, 2014. The Myth that “The Poor Response to HIV/AIDS. Washington: U.S. Can’t Pay”: Health Spending Behaviour Department of State. among Low income Consumers in Kenya. Series No. 15 18. Kenya National Health Accounts 2012/13 * Appendix 1: Interview guide

Section A: Section b: Background and description of CONTEXTUAL FACTORS project 16. Which community or group does your 1. Please tell us when the project started and organization target? Why have you chosen how did it come about (Who and what to work with this group? motivated the project/organization)? 17. How do you market your model? 2. Could you describe in detail all the various components of the model? 18. What has been the response to your organization from the communities/people 3. What was the motivation behind the you work with? model you chose? 19. Are there aspects of your organization that 4. Do you think your model has been have changed since you first started your effective? Please explain why? work?

5. What metrics have you used to assess your 20. What are the factors or activities that success as an organization? are inherent to the success of the organization? (What makes it work?) 6. What metrics are used to assure the quality of care provided? 21. What are the challenges you have experienced in implementing the model? 7. Within the health system, how does your model add value? 22. Do you think there are certain elements of your model that are dependent on 8. What is your annual revenue? the local context and cannot just be replicated? 9. How do you ensure the sustainability of the model? 23. What is your relationship with government? How are you able to interact 10. How much investment have you had? How with policy makers, on a local and national much has been donor funded? level?

11. How much turnover have you had since 24. What sort of evidence would you, as a implementation? decision-maker, like to see before you adopt a change of practice? 12. What is the cost of the service being provided? 25. What recommendations do you have for government? What other stakeholders 13. How are you seeking to expand? What is could be engaged to contribute more? your timeline for this? Interview Guide II: Experts

14. What successes are you proud of?

15. How do you see your organization as being different from other similar organizations? kenya translational research | 27

Interview Guide II: Experts

1. Why do you think that the Kenyan environment has been so receptive to innovative business models around primary care delivery?

2. What do you think are your most pressing challenges in the health sector?

3. What have been some governmental responses to these?

4. What are the private sector models and trends that have been implemented to address healthcare challenges in Kenya? (Particularly in primary care)

5. Do you think these have been successful? Please explain?

6. Why do you think these have been successful in Kenya?

7. How has the structure of the devolved healthcare system either inhibited or encouraged the proliferation of innovative business models for primary care service delivery?

8. Do you think these can be replicated somewhere else? If so, which conditions are best suited to implement these models and why?

9. What are some innovative business models or market mechanisms that you are excited about?

10. Looking at the Kenyan healthcare landscape, where do you think the next big area for innovation lies? Bertha Centre for Social Innovation & Entrepreneurship, University of Cape Town Graduate School of Business

Prepared by: Katusha de Villiers, Athenkosi Sopitshi, Dr. Lindi van Niekerk, Rachel Chater Photographers credit: Dr Lindi van Niekerk, Rachel Chater and Bev Meldrum

We would also like to thank the Center for Health Market Innovations for their generous support that made this report and research possible.

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