ReaMedica Health (RMH)

The RMH model addresses the lack of access and affordability of obstetric scanning in ANC service provision.  An integrated antenatal care (ANC) model requires a rethinking of how services are offered, accessed and sustained both clinically and financially.  Our nurse-midwife led limited obstetric scanning is a detect-and-refer model that brings affordable quality to vulnerable communities. The RMH model has provided over 300 scans in Bamburi, Mombasa, Kenya.  Eighty-five per cent of the scans performed were the mother's first obstetric scans ever. Complicated pregnancies which we were able to refer for appropriate services accounted for 11%. If affordable quality obstetric scanning were scaled globally, conservatively a maternal mortality reduction of one-half could be achieved.  This is based on a WHO report that almost 75% of women who die in childbirth would be alive if they had access to the interventions for preventing pregnancy and birth complications.

Obstetric scans are now a compulsory part of the ANC care package, however the implementation and compliance is not universal.  The implementation is hindered by the geographic accessibility of the service, its affordability and the belief by the health workers and the mothers that a scan is only needed when a complication is encountered. 

The problem RMH is solving is to include affordable quality obstetric scanning as a fundamental part of the ANC offering. Only 9% of the Kenya population has access to adequate ANC, for reasons such as financial hardship, travel hardship, lack of knowledge of services available and an acute lack of resources.  One study reported that the quality of maternal healthcare for women living in the most impoverished areas of Kenya received one-third of basic clinical ANC compared to wealthier women, who received roughly 60% of basic ANC. 

The RMH solution is nurse-midwife administered, point-of-care limited obstetric scan which is offered at one-third to one-half the price of most private facilities and is price commensurate with public facility obstetric scans. We have established satellite scanning outposts which brings the service to the community and we focus our sensitization efforts on educating the health workers to convey the importance of obstetric scans an important part of the ANC profile. The solution also includes a revenue sharing model with other health facilities, nurse-midwives and community groups. Our nurse-midwives have been trained and certified to perform limited obstetric scans using the GE VScan Access and we are adding the Philips Lumify technology in June 2020. 

The RMH target population is the Kenya mothers who receive ANC and birthing services at public hospitals.  Before any scan is administered we briefly survey the mothers about their previous scanning experiences (if any).  Our survey data shows that only 15 per cent of mothers previously had a scan.  Of the 15 per cent, approximately one-in-five (18%) accessed scans at a public facility.  Based on these findings we opened two scanning satellites in catchments near public facilities.  The satellites save mothers between 75 to 90 minutes of time accessing an obstetric scan.  For mothers and families living hand-to-mouth the time and travel expenses saved could be the difference between being able to eat or not that day. 

The dimensions of the challenge are complex precisely because they are preventable.  Service capacity limits access and affordability but attitudes toward routine scanning are misinformed leading fewer mothers being scanned fewer health professionals recommending scans. The RMH nurse-midwife limited POCUS obstetric scan expands access to high-quality, affordable care for women at price parity with the public health facilities where mothers receive ANC. Through proximity we are expanding access to high-quality, affordable care for women, new mothers, and newborns.  We know this because 85% of the mothers we scanned
received their first ever scan with us.

The uniqueness of the RMH solution is the combination of affordability, accessibility and quality assurance within a model that is offered to our target population. As a service, we are competing with private hospitals and the public health system, regarding affordability we competitive with the public facilities and independent sonographers.  Independent sonographers are not able to or choose not to scale. NGO and donor programs offering free ultrasound are not able to sustain their services beyond their funding.  While nurses who complete training programs to perform limited obstetric scanning are unable to start businesses due to capital constraints or are unable to run businesses based on scanning. Because we go to the community, mothers are seen earlier and complications detected are referred in due time while adding capacity to the public health system  scanning to the public facilities where mothers receive ANC.

Our approach was to take proven clinical processes such as imaging and approach the issue of affordable access to quality services by iterating the delivery model through the prism of a business.  Therefore, we started by modeling what the costs of service are to meet the Ministry of Health’s requirements against a price point of a public hospital focusing on operations, logistics and costs (running versus and capital). What makes the RMH solution unique is the approach RMH took to analyze and design the solution; I didn’t approach it as a health problem.    

The core technology that powers the service model solution is the portable ultrasound scanner.  RMH began with GE VScan Portable Ultrasounds.  GE VScan Portable Ultrasounds were designed specifically for a detect-and-refer model of obstetric scans to be administered by midwives.  In June 2020 RMH is adding the Philips Lumify Handheld Ultrasound.  Both portable ultrasounds are equipped with software that assist the operator at the point-of-care to capture accurate images and reporting. 

Source: the Global Innovation Exchange.  “Vscan Access is a simple, small, portable ultrasound device developed by GE Healthcare, to address SDG3 goals by tackling challenges in maternal healthcare delivery and enhance pregnancy management in primary and low resource settings. It enables midwives to detect complications and assess pregnancy risks early, providing antenatal care to mothers who need it most. The product has won multiple awards, including the prestigious iF Design Award in 2017. How does your innovation work? A user-centered design approach was taken for the development of Vscan Access, soliciting inputs from midwives, obstetricians, government officials, and human factors specialists, focusing on enabling new, ultrasound novice users, to learn quickly and use the product effectively to conduct basic screening. Vscan Access is based on a tablet computer and supports a convex probe for abdominal scanning. It has an intuitive touch screen based user interface with streamlined workflows, presets, and local language capability. Built-in real time coaching helps new users scan accurately and the ability to play e-learning videos helps with patient education. The device delivers good image quality, ability to store and transfer images via Bluetooth, as well as track fetal growth and estimate gestational age. The device has been designed to withstand power surges/spikes, can be operated on a battery and also supports solar chargers. Its small size and reasonable weight makes it possible to carry the device easily” 

https://www.youtube.com/watch?v=x-vDCGwpi2Q (GE VScan Access)

The RMH nurse-midwife limited obstetric scan model provides access to increase affordable quality access as a core part of ANC for expectant mothers which will reduce maternal and newborn morbidity and mortality rates improving cost savings for the health system and the population.  RMH internal data reveals 85% of mothers we served, received their first scans.  The RMH model provides nurse-midwife lead point-of-care ultrasounds (POCUS) the immediate outputs are the identification and referral of complicated and high-risk pregnancies which will reduce perinatal morbidity and mortality for impoverished mothers.  A 2017 five country review “Evaluation of Focused Obstetric Ultrasound Examinations by Health Care Personnel in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia”, analyzed data from 3801 examinations, and showed that 94.8% were rated as satisfactory by the reviewers and a 99.4% concordance between trainee and reviewer ultrasound diagnosis.  A significant challenge is maintaining quality assurance in non-research settings and building capacity in health organizations i.e. training nurse-midwives to scan.  The RMH nurse-midwife POCUS model includes peer scan review and external sonographer reviews (batched per 100 scans) and internal training where we have trained 11 nurse-midwives, 4 who currently work at RMH. Whilst sensitizing mothers to the importance of obstetric scans is important systemic change will occur only when nurses are sensitized to the need for imaging as a diagnostic protocol not as a tool of last resort. Our surveys indicate that 90 per cent of the mothers from the public hospital ANC programs seek a scan because they were instructed to do so by the nurse or counselor, not because they believed it to be necessary part of ANC. 

In 2020 we are averaging 33 of nurse-midwife POCUS (point-of-care ultrasound) totaling 108 scans through the end of May.  However, number of scans is extremely erratic fluctuating from 23 to 40 scans in a month. We added a second scanning outpost in April, however with no sensitization efforts possible due to COVID-19 related measures in Kenya only 4 scans were conducted at the second location.  With marketing to the community and nurse sensitization efforts we expect to double our numbers while adding a third scanning outpost in September.  By November 2020 we project 85-90 scans a month but a 2020 monthly average of 70-75. We anticipate approximately 850 paid scans for 2020.  We are in discussions to conduct a research study which would provide free nurse-midwife limited obstetric scans for 100 mothers monthly beginning in September 2020 for a 12 month period.  In five years our goal is to directly provide 1,000 each month and through franchising 10,000 scans a month.

At the end of 2019, in addition to our clinic we added a POCUS (point-of-care-ultrasound) only scanning satellite location and in April 2020 we added a second scanning only satellite location.  We are planning for a third POCUS satellite in September and a second full clinic in November.  We are in discussions with several NGO’s to conduct mobile scanning in counties throughout Kenya.  Also it is our intention to add machine-learning capabilities, specifically for obstetric scanning as a detect-and-refer model, to bolster our quality assurance capabilities and then licenses the technologies to other organizations and providers.  This was intended to be rolled out in 2020 but we’ve come to an impasse with our technology partner and now intend to bring machine learning capability in-house at a future point.  As we increase the number of scans the macro impact of POCUS is to support a sustainable system of Universal Health Coverage (UHC).  The RMH model is founded on the principles of Value-Based Healthcare (VBHC) which is the only way that UHC can be successfully implemented.  We intend to grow organically but are open to investment and funding which will let us scale in Kenya and externally inclusive of a franchising option.   

As mentioned, 85% of the mothers scanned are receiving their first scan but mainly because they were instructed to do so by a nurse.  What has been a revelation is that nurses in facilities outside of urban areas do not feel that ultrasounds are necessary for ANC, although it is a care protocol for ANC by the Ministry of Health and the WHO.  It took nearly 9 months working with the facilities near our first POCUS scanning only satellite to encourage nurse-midwives to consistently refer mothers for obstetric scans. Initially for the first three months we would have less than 10 scans in a month. We then interviewed mothers and nurse-midwives to understand the low turnout.  Mothers and more alarmingly nurse-midwives felt that scans were only necessary in emergency situations. After months of education to nurse-midwives the numbers improved.       

A disheartening problem has been unstable partnerships and unfulfilled contractual obligations.  We have partnered with health associations, various providers and NGO’s who are presenting our work and model as their own in proposals, grant applications and communications with the Ministry of Health.  Financially, the expansion capital as our equipment and medical devices require significant upfront capital expenditure.  However, the most significant and problematic challenge has been quality hires and overcoming corruption on an individual and systemic level.  We have had a high turnover of personnel for reasons of theft and side deals with health facilities as well as lengthy waiting periods for permits, paperwork and inspections. 

Nurse-midwife buy-in: with each new POCUS satellite we are spending much more time and effort to sensitize facilities staff to the importance and regulations for scanning to be part of the ANC profile whereas before efforts were focused solely on the mothers. 

Partnerships: the selection of partners has been problematic and requires much more diligence by us into previous projects and partnerships of the organization being considered.  

Personnel turnover: we continue to expand our hiring outreach and expand the pool of candidates we interview. We have also adjusted our probationary hire period requirements and review standards.  Finances permitting, we will run background checks with an HR consultant but we must find references outside of those provided.

Corruption:  the issues we face with corruption are being addressed by continuing to push the processes that are outlined and mandated and documenting all of our activities and communications.  RMH used the CarePay MTIBA mobile health payment system for patients, financial software for accounting and intends to add an electronic health records system that will integrate with the financial software, funds permitting, by Q4 2020. This has and is taking up a significant amount of our staff's time in pursuing our permits, inspections and corresponding accreditation. Mainly we build into our planning lengthy delays and allocating resources dedicated to follow-up and also understand that we must walk away from some opportunities.

As of June 2020 for nurse-led POCUS - 4 FTE nurse-midwifes trained to provide limited obstetric scans.  

As a clinic of June 2020 – 9 FTE, 4 part-time staff, 4 ad-hoc contractors

The strength of our team's skills and background is that our staff, aside from myself, is completely Kenyan.  RMH is a Kenyan entity not only legally but also in terms of staff, advisors and whenever possible business partners.   

With our team we have been able and forced to continually iterate our model within a Value Based Healthcare framework, balancing clinical standards and financial sustainability for growth 

Penina Mulwa: Nurse and Head of operations has 18 years of work experience across Kenya public health, NGO projects and the private sector, including operating her own clinic and others in the past.  Her experience as a public health worker and private clinic owner provides insight and guidance to our model's configuration and growth.

Michael Seo:  I am the Managing Partner and founder.  My focus and experience working on health entrepreneurship in low-resource setting began in 2007.  My experience in marketing and management consulting as well as running his own business brings a non-clinical perspective and focus on operations and management. As a non-clinician and being new to the Kenya health system I, often unintentionally, challenge the status quo and force us to think of other ways to deliver our services.  

Partnerships have been a treacherous undertaking to-date and over the past six months we have terminated all previous engagements. However, in June we begin a six-months PharmAccess and the Philips Foundation pilot to analyze pricing for impoverished communities, assessing the viability of a business case for independent single location facilities to offer ultrasound services. 

RMH is a for-profit social enterprise whose customers are the impoverished, working poor and middle class expectant mothers typically seeking services at public health facilities. Beneficiaries are the families and partner health providers. The clinic business model provides value to vulnerable populations for primary care services and within the model is an emphasis on affordable access to quality POCUS as part of the ANC care regime  for expectant mothers. We achieve affordability and quality outcomes through a VBHC framework focused on a nurse-midwife led model of diagnostic, educational and women's reproductive health services.  Our pricing is designed for pricing parity within 10-15% of public facilities (although not possible at times).  We also work with private facilities on a referral revenue share model allowing their patients to receive services and return to the health providers without disrupting the established patient-caregiver relationship.  In cooperation with the county departments of health we are in discussions to share data and eventually work on a more collaborative model of access that will address service gaps or help alleviate facilities that do not have the capacity to meet the demand for services. We are expanding into primary care insurance segment in Q3 2020.  

Currently we are a low-income client model for ANC POCUS.  However, in Q3 2020 RMH will be adding middle-income insured clients as we were in the last inspections for several health insurance companies prior to the COVID-19 lock down in Kenya.  We anticipate finalization for inclusion in their provider networks by the end of July. Conservative revenue projects estimate that RMH at cash flow neutral by the end of August through the insured revenue. While we will continue to seek grant funding, donor or grant funding is not intended to cover day-to-day operation costs and expenses.  However, grants can be a strategic tool for catalytic growth and assessing the viability of additional services without a profit rationale or a purely community impact objective. 

The east Africa health sector is predominately public sector, NGO and donor driven and for our solution to scale rapidly we need to connect with them not necessarily as funders but stakeholders and collaborative partners willing to improve access for our target mothers and communities.  The Solve partnership platform would help us access partners, expertise (MIT Faculty and the community of Solvers) and resources (donor, governmental, technical and other solvers) that we currently do not have the ability or pathways to access. We know that the solution is clinically proven but partnerships have been troublesome. We have made some progress in accessing the investor community and private health provider space but have made little progress in the community of partners that programs like Solve cultivate and curate.

Solution technology-funding - Seeking funding to build the machine-learning capabilities, we have already identified at technology vendor to build it. 

Product/service distribution -  Seeking to partner with the county level departments of health directly as intermediaries have co-opted the process to our exclusion

Legal or regulatory – nurse-midwives are only able to attach their license credentials to one facility unlike doctors who can attach them to multiple locations.  In a nurse-led model that severely constrains growth.

USAID and DFID - funding for scale but more importantly access to them to establish a line of communication about our work and their stakeholder networks

Solve Members - looking for areas of collaboration

Gates Foundation - funding and support to scale in other countries

MIT Faculty - expert advice and guidance, publishing as well as research opportunities  

The foundation of the RMH solution is a task-sharing model that expands and support the health workforce for newborns, pregnant women, and new mothers in low-middle-income-countries with the goal of significantly reducing prenatal morbidity and mortality rates.  Our internal capacity building expands the capabilities of existing health workers by improving the workers' assessment and referral capabilities through proven diagnostic imaging.