Problem: What problem is this project trying to address?
Only five percent of Kenya’s population has public health insurance under the National Hospital Insurance Fund, which relies on contributions from formally employed Kenyans to cover health benefits for members and their dependents. Only two percent can afford private health insurance for high quality health care at designated private health facilities. 85% of Kenyans do not fall within the formal employment bracket and do nott earn enough to afford private health insurance. Thus, some thirty four million people are not covered by any form of health insurance and can only access health care services that operate on a cash-for-service basis.
This alarmingly low level of health insurance coverage in Kenya has persisted for many years because the old health insurance model was designed to only reach a very small, specific and easy-to-reach market of formal employees. Insurance providers prefer to work with formally employed individuals because it is easy to collect their premiums. Their employers make an automatic monthly deduction off their salaries and send that money to the insurer. In fact, the ease with which remittances flow to the insurer once an account is acquired is so enticing that the entire health insurance industry will clamor for a share of the few Kenyans who fall in this category every year. Given current practices, other market segments do not seem viable to the traditional insurer. More importantly, there is no other insurance provider that demonstrates the possibility of reaching other market segments.
Private providers offer the highest quality and most reliable health care but uninsured Kenyans cannot afford these services. Public hospitals, clinics and health centers account for 40% of Kenya’s health care space and should provide subsidized and, therefore, affordable health care services to the majority of Kenyan’s- whether covered by insurance or not. However, the reality on the ground is that they are unable to provide quality services due to a serious lack of supplies and staff capacity. This lack of capacity greatly undermines the level of efficiency of public health centers. It is common to find lines of up to hundreds at a health center- all waiting to be seen by one doctor. Doctors in public health centers often hold another job at a private hospital, clinic or pharmacy that pays more and, therefore, takes up most of their time. Patients walk long distances to reach such centers and can wait for up to four days to receive treatment. Even those with insurance must beat the lines in order to see a doctor. Due to inadequate drug supplies, patients will often get a written prescription that they have to take to a private pharmacy that charges a fee. NGO health centers account for 30% of the health care space and provide the best balance between price and quality. However, their dependence on grant money makes these unsustainable and, therefore, inconsistent over the long term. Private health care providers account for the other 30% and these are the most sustainable and most efficiently run operations by far. They attract the best doctors and provide good quality health care. The problem with these is that they are hardly affordable to the average Kenyan and, by virtue of their pricing, almost exclusively serve middle to upper income populations.
Solution: What is the proposed solution? Please be specific!
Sam is giving low to middle income earners, who are not served by the current health insurance market, the ability to access affordable and quality health care services. He is doing this by leveraging the existing reach and efficiency of telecommunications infrastructure to enable anyone with a mobile phone to use it in combination with an easily accessible smart card, and electronically save for health care in a convenient manner and in amounts they can afford. He is getting private health care providers to fix their charges at a much lower price point and is using a paperless process to revolutionize the speed and efficiency with which claims are processed and remittances are made to service providers.
Sam is not only building the architecture that will make affordable and quality health care accessible to the 95% of Kenyans currently uncovered by conventional health insurance models, but his game changing idea is transforming the focus of health insurance in Kenya from institutional to individual membership. He is making it possible for health coverage to be shared among friends and family, and for people and institutions to contribute to the coverage of any individual(s) directly. In addition to transforming the health insurance sector, he is also looking to change individual behavior. By making quality health care far more accessible and affordable, Sam looks to improve the health seeking behavior of Kenyans. He finds that a lot more people are making the choice to seek professional medical help early enough, rather than self-medicating or waiting until they deteriorate into a more severe condition.