Health "Kiosks" for Kenya Slums

Competition Finalist

This entry has been selected as a finalist in the
Transforming Health Systems: Gamechanging Business Models competition.

Project

This innovation also has a Project Page where you can read more about its latest progress.
Go to Project: "Micro-Clinics" for Kenyan Slums.

Access Afya is creating a chain of ultra-mini-clinics that provide standardized outpatient services targeting the extreme poor. Health technologies support operations and patient communication. This model lowers barriers to good health by bringing care directly to the doorstep of the people who need it the most. The clinic links to existing community networks for outreach and health financing.

Organization Name

Access Afya

Organization Website

About You

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About You

First Name

Melissa

Last Name

Menke

Innovation

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Name Your Entry

Health "Kiosks" for Kenya Slums

Explain what the "innovation" is about, e.g., is it the idea and/or the model you use to accomplish the idea, or your understanding of the target population, etc.?

Access Afya is redefining the healthcare experience at the base of the pyramid through a community based mini-clinic model. There are many innovations in new diagnostics, products, and apps but there is a bottleneck getting these to mass markets. We are taking a completely different approach to healthcare by creating clinics in vulnerable populations, staffing them with qualified health professionals, equipping them with the latest health technologies and diagnostics, and linking to a larger referral network to handle advanced health needs.

The model is a private sector solution for poor markets, charging small fees for each service. Patients are offered a variety of health financing options to meet their small, irregular cash flows from pay-per-use products and services to bundled care packages to membership plans. We build on the existing community social infrastructure, through community health workers, savings groups, and schools, to promote our products and screen potential clients.

We are planning each element of the organization for scale, from recruitment and hiring criteria to training plans to clinical and operational protocols. Technology is the backbone of this vision, as all records are already managed electronically. Smart health systems will increase efficiency through saving space and reducing repetitive data collection, and improve outcomes through diagnostic protocols and treatment reminders. As we expand, small positive margins from each mini-clinic will contribute to operational overheads, making the model self-sustaining at scale.

Describe how your innovation model is distinct from any other organization in your field?

The status quo if you are sick and poor in Kenya is to either spend time and transit money to go to a public facility, where you then spend hours waiting for treatment, or to self-diagnose and purchase medication from an unregulated chemist. Chemists are rarely staffed by health professionals, nor do they have training or tests to give an accurate diagnosis. Charitable programs exist but cannot reach the millions living in poverty and are heavily subsidized.

Other health enterprises in Kenya such as do not target the ultra-poor, or they focus only on specific needs such as maternity or HIV/AIDS. We bring a holistic healthcare model directly to the doorsteps of the people who need it the most.

What type of operating environment and internal organizational factors make your innovation successful?

The business model fits into Ministry of Health strategy and goals, including increasing primary care, services for expectant mothers, public-private partnerships, and health technologies. Our partnership with the public sector, from licensing to reporting to receiving free supplies, makes the model more feasible and scalable. Nairobi is emerging as Africa’s Silicon Savannah, giving us many organizations and individuals to partner on tech innovations. Mobile penetration is high, meaning our text message communication strategies are feasible here. We also have strong local support networks, and a solid knowledge of our target market through our growing electronic database of our patients' demographics, symptoms, treatments and also process documents from the pilot.

How do you make sure you constantly innovate in light of (potential) external challenges, or your growth plan?

We currently have weekly all staff meetings to facilitate challenge and idea sharing. I have also engaged interns and external student groups to study our model, financials, interview previous patients, and provide feedback and recommendations.

I have been a contributor to global health networks, blogs, and conferences as well as frequently posting on our website. This demonstrates that I am ready and willing to share our ideas, progress, challenges, and solicit feedback and ideas from others. I have learned a lot from mentors and advisors, and believe that open, honest dialog about our model and challenges will keep us nimble and innovative. Social impact is the primary goal, and if the path to that goal is constantly changing our organization is prepared for that.

Business Model

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The systemic challenge you are trying to overcome (select one)

Bring accessible healthcare to communities in emerging markets

Health area (target market) where the need is [select only one]

Primary healthcare services

Categories along the health continuum you are covering [select all that apply]

Prevention, Detection, Intervention, Follow-up, Long-term care, Social integration.

Please describe in more detail: what problem are you trying to solve in the organization's specific context?

In Kenya 9 out of 100 children will not live to see their fifth birthday. Wealth is a major determinate of health; the poor are less likely to access preventative and life-saving treatments, to use family planning, and to know their HIV status. This leads to unnecessary suffering and death from preventable and manageable conditions.

Slum conditions exacerbate disease, where 150 families can share a latrine, just over half of homes treat their water, and registered clinics are rare. The National Health Accounts finds that 30% of Kenyans do not seek care when sick, citing cost and access as key reasons. Most health-seeking behavior at the base of the pyramid centers around waiting for conditions to exacerbate and medication is usually purchased from informal, unregulated chemists.

Stage that best applies to your solution [select only one]

Piloting (a pilot that has just begun operating)

Core strategies of your business model [select all that apply]

Approaches to behavioral change at the individual level, New/redefined roles for healthcare service provision, New approaches to distribution of health products and services, New financing strategies for health.

If other, specify here:

Most relevant tools you are using to implement the strategies outlined above [select only two]

Technology, Consultation.

If other, specify here:

Please describe your solution in more detail

Access Afya is creating a chain of ultra-mini-clinics that provide standardized outpatient services targeting the extreme poor. This model lowers barriers to good health by bringing care directly to the doorstep of the people who need it the most. Through community marketing and convenient proximity, patients are encouraged to have earlier, more frequent conversations about their health.

Each clinic has a registered nurse on site, supported by electronic health systems to manage patient files, stock, and communication. There is a consultation room, mini-lab, and a dispensary to fill prescriptions right on site. The clinic is open every day for ten hours. Patients pay small fees for each service, making the model self-sustainting.

What are your vision and overall objectives?

There is a massive opportunity to reach the millions in poverty with a private, affordable, social health enterprise model. Despite common perceptions, there is a willingness to pay for health services at the base of the pyramid. This is evidenced by the prevalence of informal chemists profitably peddling medications in the slums, and the early successes of organizations around the world rolling out low-cost clinic models. More evidence is coming in through the Access Afya pilot site. Technology is transforming the way medical workers and facilities diagnose diseases, manage conditions, and engage with their patients, and we use these to lower costs and improve outcomes. After its pilot, Access Afya will expand with a branded chain of mini-clinics serving poor markets in Kenya and beyond.

What is your value proposition?

Our clinics are cleaner, better stocked, and more convenient options than public health centers, while being more reliable sources of information and supplies than surrounding informal chemists. Diagnoses are accurate because the clinic has registered medical staff and rapid diagnostic tests. Care is friendlier because we have quality control checks and protocols for treatment and follow-up. We link to existing community groups, making payments easier by lumping them in with school fees or savings groups. The brand Access Afya will be a name people come to trust, providing a consistent, quality, convenient experience.

Who is your customer(s)?

The Kenyan population is 43 million with around half living in poverty. We target these base of the pyramid customers in catchment areas of around 5,000. We emphasize services for women through prenatal outreach because women are often health decision makers in the household and likely to bring their children and refer their friends. A secondary target group is youth. 43% of Kenya’s population is under 15, they are a growing force in the country, and we reach them early through talks on sexual and reproductive health. Our customers have low, irregular incomes, work in the informal sector, live in households with an average size of five, and do not have health insurance.

What approaches to you use to reach your customers?

The clinic markets itself partially through design and materials, which send a message about our permanence and commitment to quality. A permanent, physical structure in a dense, urban area is part of how we generate traffic for our services. Design elements include a front window where our community health worker can interact with passers-by and sell over the counter. We are open seven days a week, from 8:00am to 6:00pm.

Our core sales force is our cadre of community health workers—government appointed health volunteers who are already doing home-based care with an emphasis on HIV/AIDS. We equip these workers with information on Access Afya to facilitate referrals. The clinic team does health and outreach talks with existing community groups. We are experimenting with SMS promotions.

What are your primary activities?

Access Afya is redefining each element of the health delivery value chain with rigorous attention to cost, quality, and scalability. We start with the physical space. The average plot size in the slums is 12 x 15 feet, meaning a full outpatient center needs to fit in this. We design and construct clinics, and negotiate land and lease arrangements and stock them with reliable supplies. Next, we recruit, hire, train, and support health staff. Pre-screening systems, group interviews, and mock consultations help find the right people. At the core of the model is excellent service delivery. Our staff gives consultations on common ailments, family planning, prenatal care, and perform first aid. We follow up with each patient via SMS reminding them of treatment and to check back in.

Who are your peers and competitors? What problems could these players pose to your success or growth?

The largest competition is from informal chemists, who are unregulated but ubiquitous sellers of medication through small shacks. Competing with the unregulated drug supply chain, where up to a third of drugs are expired or stolen, we might not always win on price and must establish a reputation for quality. Chemists do not have the staff or supplies to offer our services. Quality private facilities are serving mostly upper-middle income and above. Large networks of healthcare providers could look to go down-market. These organizations have an advantage from their experience managing large healthcare organizations, but they are currently nowhere near our market. Additionally, we are tailoring our model for the urban poor, and will have an advantage in reaching this population.

What other challenges - individual, organizational, or environmental – are you currently facing or might hinder future success of your business, and how do you plan to overcome those?

Weak land rights in informal settlements is a risk to quickly expanding in number. Engaging the public sector in lease negotiations overseen by our chief to having Ministry of Health visit the site reduces this risk, and a mini-clinic model spreads the risk of any single land title across many sites. Infrastructure costs are low but concrete walls strong. A similar organization in the education space invested in a strong legal team, and we may have to do the same. The model rests on excellent staff, and rapid growth and replication. A competitive HR package and building positive organizational culture through staff meetings and training opportunities will help attract and retain staff. Our various technology systems are not integrated, and we need to invest in a seamless eHealth platform.

Briefly describe your growth strategy going forward

Following one additional pilot site in 2013, we will start to roll out the mini-clinic model in urban areas. An estimated 3 million Kenyans live in urban informal settlements, and we will start expanding within Nairobi and other urban areas. In parallel, we will pilot our rural model for bringing the same standard of care to rural communities, and use this data to craft a rural expansion plan.

What dimensions for growth are you currently targeting for your innovation [select all that apply]

New regions(s).

What makes your business "ready" for growth?

In four months we have attracted 400 patients, residents of our target slum, who are paying small fees for health services. Countless more purchase supplies over the counter. Daily traffic and sales are increasing, and the market for primary care for the poor is vast. We've developed processes and protocols for operations and are ready to test these and our ability to run a mini-clinic chain.

What are your key growth objectives?

Expansion goals are to explore variation in customer preferences in different areas, add new products and services and learn about willingness to pay for these, increase marketing and outreach, invest in protocol development and technology integration, and create a prototype for an improved clinic design. As we expand we will also explore economies of scale with resource accumulation and spreading

What is your timeframe for growth, in the short and mid-term? What are the growth milestones and key activities going forward?

This year we are experimenting with new marketing and health financing strategies to increase clinic throughput, and will open one additional site. Medium term expansion will be through a cluster model, quickly opening up pods of mini-clinics in slums allowing us to leverage referral networks and relationships. We aim to be operating 15 mini-clinics in urban areas and have a rural pilot by the end of 2015.

Key milestones will be expanding traffic to 15 patients per day, increasing the core team, signing a bulk purchasing agreement with our largest supplier, obtaining the highest level of SafeCare certification illustrating our quality standards, partnering with at least one insurance provider, and signing up half of our patients for membership, packages, or health savings products.

Organization Country

United States, NY, New York

Social Impact

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What has been the impact of your solution to date?

The pilot opened December 3, 2012 and has been providing consultations, wound dressings, rapid diagnostic tests, vitals monitoring, and sales of medications and health supplies. In just ten weeks the clinic did over 100 consultations, 25 family planning visits, dressed 16 wounds, and ran 34 tests. An essential piece of our marketing strategy, health talks also transfer information to targeted groups such as women living with HIV support networks, savings groups, and secondary schools. We held our first large outreach event, a deworming campaign, and had 176 children come to the clinic in two days.

Patient feedback is incredibly positive. Through follow-up surveys, all interviewed patients have told us they felt better within five days of their appointment, and felt as through they were treated with respect. Many told us the attention paid to them by health staff was the best thing about the clinic and the reason they will go back. One women explained that she did not know family planning pills were to be taken at the same time each day prior to talking with our nurse. Another woman with frequent asthma attacks is saving for an inhaler with us instead of relying on reactive injections. Multiple men who have tried to purchase malaria medication over the counter have been surprised to pay for a blood test and learn that their fever was not caused by malaria. Word of mouth is spreading, and early anecdotes demonstrate the huge social value of having reliable health information within the community.

What methods for quantification of social impact are you applying (if at all)?

We opened our pilot clinic in December, and are tracking services as outputs. Through quickbooks, we run reports on total and monthly sales of health supplies and services. The desired outcome is that our services create wellness. Our follow-ups with patients confirm this early on, and we are looking at tracking systems that can summarize outcomes for all patients. We want to understand which of our services are saving our patients time and money in comparison to their next best alternative, versus which are services that would not have been consumed if our clinic had not been there.

Could your solution work in other geographies or regions? If so, where?

The model could be replicated throughout East Africa, and has potential to spread further. Distributed healthcare in smaller and more convenient spaces is the future of healthcare and will work through quality protocols, health supply chain work, linkages to existing community structures and networks, and design. I am committed to sharing our model and our learning, so that as Access Afya grows, other organizations can take the methods and approaches and implement them in other markets as well. Technology, marketing strategies, and protocols will be adapted to local contexts, but the core vision and value chain will translate.

What is your projected impact over the next 1-3 years?

In the next three years, half of the three million residents in Kenyan slums will have access to reliable healthcare. This means 33 clinics serving an estimated half million without a current health center. Each clinic will reduce infectious disease through proper diagnosis and treatment. 9.2% of children in Kenya die before their 5th birthday; 55% of these deaths are due to malaria and respiratory disease, which can be diagnosed and treated at the clinic level. There will be a drop in unsafe abortion because more women are using family planning. Family sizes will be lower, and women will have more time to work. Maternal mortality will decline because of our antenatal services. Health knowledge will be democratized, as even HIV tests can happen quickly, inexpensively, and privately.

Organization's Country of Operation

Kenya, CE, Nairobi

Type of Organization

For‐profit

Sustainability

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Elaborate on your current financing strategy

Financing currently comes from a social investor and will fully cover operating costs through May 2014. Access Afya is seeking charitable funding to help study and expand the pilot. Charitable funding would be dedicated to opening an additional site, integrating technology systems, and covering core operations. We are applying for grants, fellowships, and launching a crowd-funding campaign to tap into social networks.

Each mini-clinic will take around one year to break even, and the Kenyan organization will be able to sustain itself when it is operating 15. The pilot site is generating revenue that currently covers around half of its operating costs and all revenue is used directly for operations. Once the sustainability case is proven through the expanded pilot, Access Afya will seek social investment to increase the number of mini-clinics. At this point we will also be exploring other forms of financing, such as partnerships with insurance to increase earned revenue. Another option is local capital, such as constituency development funds, which will be allocated by the newly elected government and is in-line with Kenya's decentralization goals.

Share of revenue generation in total income of organization (in percent)

10

Direct sales to patients or other beneficiaries (in percent)

100

Of the possible sources of these sales listed below, check all that apply to your current strategy

Friends and family, Individuals, Patients.

Licensing fees, e.g., for technology/franchise model (in percent)

Of the possible sources of these licensing opportunities listed below, check all that apply to your current strategy

Service contract with organizations, e.g., government, NGOs (in percent)

Of the possible sources of the service contracts listed below, check all that apply to your current strategy

Explain your revenue generation strategy in more detail

Revenue is generated through a combination of products and services. Consultations and other services are priced low- around $1.25 for an adult consultation- to get people in the door, and memberships and packages make these margins slimmer. We make the larger shares of revenue on testing and medicine and product sales. Lab tests and injections have an average 60% mark-up, and medicine and supplies average 40%. Most patients pay for a test or medication as a result of consultation. Around half of revenue comes from the retail window selling basic health supplies. Each mini-clinic will operate on slim positive net income, contributing to organizational overheads.

Share of philanthropy in total income of organization (in percent)

90

Philanthrophy strategies you are using

Diversified strategy.

Explain your philanthropic approach in more detail

The 90% is currently not actually philanthropy but social investment capital. Moving forward, we aim to diversify philanthropic capital to include grants and fellowships. The strategy is to use philanthropy to test new ideas, such as marketing primary care memberships, integrating mobile money savings products, and expanding to a rural pilot, while keeping the long-term model to have each mini-clinic fully cover its own operating costs.

Expand on your selections; explain how you will sustain funding over the next 1-3 years.

We have funding for the next year, and are raising charitable funding to cover an operating loss for the next three years. The mini-clinics contribute to their own operating expenses and we see our revenues growing throughout our early months. Additionally, there are a number of future revenue streams we are exploring: expanded service delivery menu to include more lab work, other health and sanitation services such as providing clean water, collaborations on data collection and sharing, and leveraging our messaging and community health worker networks for advertising.

Year of launch of the organization

2012

Years in Operation

Operating for less than a year

Has the organization received awards or honors? Please tell us about them

Access Ayfa was selected to be part of the inaugural Village Capital Nairobi program, which involved peer exchanges, mentor matching, and business plan coaching with a local consulting group and 15 Kenyan start-ups.

Founder Melissa Menke is also a current semi-finalist for an Echoing Green fellowship.

We want to hear about your “Aha!” moment. Share the story of where and when the founder(s) saw this solution’s potential to change the world.

In Co-Founder Duncan’s extensive microfinance experience, he saw how treatable health issues caused problems for clients in loan repayments. This prompted us to brainstorm new health models in November 2011. We discussed a ‘health kiosk’ that lowered the time-burden of seeking care, and I developed the concept through a trip to Kenya where I met with stakeholders and saw the potential impact.

65 weeks ago Health "Kiosks" for Kenya Slums has been chosen as a finalist in Transforming Health Systems: Gamechanging Business Models.
72 weeks ago Melissa Menke submitted this idea.