Clinical Decision Support at Penda Health

Penda’s solution resolves the problem of waste in primary healthcare. Waste in healthcare is well-documented worldwide, affecting both rich and poor countries.  A report from the National Academy of Medicine estimates that 30% to over 50% of healthcare spending is considered wasteful as a result of inefficient and unnecessary use of resources in the healthcare sector as a result of different factors such as duplication of services, inefficient processes, overly expensive inputs, error, etc. These components lead to increased costs and reduced quality of care for patients. 

Much of the waste occurs because it is challenging to provide guideline-based care consistently at scale.  In Kenya, the Ministry of Health has estimated that only about 40% of healthcare provided to Kenyans is in line with clinical guidelines (MoH citation, 2019).  Non-conformity with clinical practice guidelines is at best wasteful, and at worst, directly harmful to patients.  While healthcare waste in any country is bad, it is particularly painful in a low-resource setting, where it is imperative that we squeeze maximum value out of the limited resources that are spent on healthcare.  Worldwide, there are billions of people who are affected by the waste in primary healthcare, but we estimate that the bottom billion really suffer from this waste.

At Penda, we see the human side of these statistics when patients come to us for care after being treated in other facilities.  Misdiagnosis, over-treatment, under-treatment, and incorrect treatment are all too common.  When our patients are victims of this problem, they end up wasting the precious few resources they are able to spend on healthcare.  Our patients are frustrated by wasting money on low-value care and want an option they can trust.

There are two main systemic factors that contribute to low guideline adherence in Kenya.  First, the scope of primary care in Kenya is extremely broad: Clinicians in our setting treat more than 300 conditions regularly, which range from well-baby care to chronic disease management, to trauma from industrial injuries or motor vehicle accidents, to mental health concerns.  Non-physician healthcare providers, such as nurses and clinical officers, provide the bulk of primary healthcare in Kenya.  Robust, broadly-implemented clinical decision support is needed to support non-physician healthcare providers in the extremely broad range of conditions they commonly encounter.

The second factor leading to low guideline adherence is the profit motive that many small clinics operate under.  With limited funds and variable patient flow, there is a strong incentive to over-diagnose and over-treat patients that come to the facility.  This results in the provision of un-indicated diagnostic testing and excessive use of pharmacological products, particularly antibiotics.  Improving clinical guideline adherence is a direct way to measure and overcome these problems.

Penda’s solution is a knowledge-based clinical decision support system embedded in our electronic health record.  In other words, our frontline clinicians are proactively shown clinical guidelines for the diagnoses they identify as they go through their typical workflow.  The guideline recommendations are actionable with a single click to allow recommendations such as lab testing, prescription recommendations, referrals, and more to be directly added to the patient’s record.  By integrating the recommendations into the point-of-care workflow, we make the guideline recommendations the “path of least resistance” which improves our guideline adherence to more than double the national average and improves clinician knowledge and satisfaction.

Our Clinical Decision Support System (CDSS) is a web application that connects to electronic health records via APIs.  It is conceptually very simple: Imagine a spreadsheet with an “input” column, which could be a patient concern, like “missed period,” or a diagnosis made by the clinician, like “uncomplicated malaria.”  The cells in the input column are related to cells in an “recommendation” column that contain guideline recommendations related to the input.  For example, a urine pregnancy test will be returned for a patient’s concern for delayed menses.  Ministry of Health guidelines on malaria treatment are returned when a diagnosis of malaria is entered.

As Penda’s frontline clinicians progress through their typical workflow with the patient, the guideline recommendations are returned within the electronic health record, and clinicians must accept or reject the suggestions before closing the visit.  Guideline recommendations that are accepted automatically become part of the medical record as lab or pharmacy orders, depending on the suggestion.

Any simple outpatient electronic health record can integrate with this clinical decision support tool.  The EHR must have lab and drug order entry, as well as structured data fields (rather than free text) for patient concerns and diagnoses.  The most challenging part of implementation is the cultural change of bringing guideline adherence to the forefront of primary healthcare service delivery.  From a technology standpoint, any mobile internet (3G or better) is sufficient, and any outpatient EHR designed for LMICs such as OpenMRS can integrate with the CDSS.  Most outpatient EHRs are device-agnostic and could be accessed via laptop, tablet, or even a mobile phone.

CDSS is absolutely essential to low-resource countries.  Over the last five years, we’ve seen both public and private health systems in low-income countries adopt electronic medical records systems, but yet care processes have not improved significantly.  To fully reap the benefits of the EHR investments, it is imperative that organizations embed broad clinical decision support systems.  For a fraction of the cost of the original EHR investment, organizations can dramatically improve guideline adherence, thereby doubling the value of the services they provide to patients.

Regarding the primary healthcare data, the beauty of this CDS implementation is that it is both a point-of-care intervention and an automated measurement tool.  By offering guideline recommendations within the standard workflow, it simultaneously influences the care provided and provides a real-time window into process measure adherence that can be assessed at the system level, clinic level, or even down to the individual clinician.  A simple dashboard built from categorical accept/reject data can display the guideline adherence over time and across geographies, while also highlighting areas of low adherence which should prompt deeper assessment from clinical leaders.  A major advantage of this approach is that additional data collection or chart review is not needed – the primary clinical workflow automatically generates the categorical data that local leaders need in order to know the quality of primary care being provided and the steps needed to improve it.

Penda’s approach to CDS also naturally embeds a quantitative feedback loop for local leaders and frontline staff.  Not only do hospital and clinic leaders have a direct measure of the quality of care they provide, but we encourage the adherence dashboards to be shared directly with frontline clinicians and local clinic leadership.  When frontline staff have a real-time KPI for the quality of care they deliver, they can become much more engaged in quality improvement efforts.  We have also found that as clinicians become more familiar with their own performance on guideline adherence, they tend to make very valuable recommendations regarding the guidelines themselves.  We have been able to make considerable improvements to our clinical guidelines based on frontline clinician feedback because our frontline staff are so engaged with this KPI.

At Penda, we have found the KPI of clinical guideline adherence, as represented by the accept/reject rate of clinical guideline recommendations at the point of care, to be very influential with our major stakeholders.  Insurance companies and other payers, regulators, third-party auditors, and patient advocacy groups are quite interested in our approach and it has been important for our growth as a thought leader in the sector.

Our solution not only targets the ‘common mwananchi’ earning between $2-$5 but generally, anyone in need of quality healthcare. Our target population, low and middle-income Kenyans, do not have access to medical insurance,  a ‘key’ to high-quality medical services. Penda Health aims to provide high-quality primary healthcare services to this population who, without access to Penda, have poor options for affordable medical care. 

As a primary healthcare provider, Penda offers care to everyone, regardless of age, gender, profession, or the payment method.  We take care of the full spectrum of patients from cradle to grave.  Across the more than one million patients that Penda has served over the last ten years, women make up about 60% of our adult visits, and children under the age of 18 represent more than 40% of visits (and about half of those are under five years old).  Our patients typically live and work in and around Nairobi, where we have 19 physical medical centers in Nairobi, Kiambu, and Kajiado counties in Kenya.  In addition, our telemedicine and drug-delivery platform is accessible to people living anywhere in Kenya, and approximately 25% of telemedicine visits are from outside our physical catchment area. 

Our solution impacts more than 90% of patients who receive care at Penda.  We are continuing to build out decision support tools for the remaining 10% of patients who have uncommon conditions not currently covered by our CDS system.  The impact of our CDS system on our patients is tremendous – the provision of guideline-recommended care is more than twice the national average, and continues to improve.  The end result for our patients is that they get more than twice the value out of their limited healthcare spend that they would get in other facilities.  This leads to healthier communities without raising costs for patients.

Founded in 2012, Penda Health is an award-winning, social enterprise that provides high-quality primary healthcare services to low-income families who otherwise cannot access trustworthy, affordable medical care in urban and peri-urban Nairobi, Kenya.  

Penda has three unique superpowers:  

First, as a consumer-driven business, we are primarily committed to the overall experience of our patients.  We know our patients will “vote with their feet” when it comes to where they seek healthcare and therefore our deepest commitment is to understand the needs of our patients and to design an overall healthcare experience with them in mind.  This commitment has manifested in many ways, from the physical design of our clinics to our choice of WhatsApp as an ideal patient communication tool. Our routine follow-up calls to patients have allowed us to not only better serve our clients' medical needs, but also provide immediate first-hand feedback on the overall patient experience.  Over ten years, we have amassed detailed quantitative and qualitative data regarding the patient experience of our target market from hundreds of thousands of people and we now understand our patient needs better than any other healthcare organization in the region.

Second, as one of the busiest outpatient healthcare providers in all of East Africa, with a geographic footprint that reaches nearly 8 million people and a well-established brand, Penda is well-positioned to roll out new products and services that can achieve immediate uptake.  For example, when we first launched our WhatsApp chat service, we had 3000 monthly active users in the very first month.  We have established a pattern of rolling out initiatives, seeking out feedback from patients and staff, and iterating on the product and process by incorporating and prioritizing feedback. 

Finally, we have cultivated a team of 390 continuously trained and tech-enabled staff who are deeply aligned with our mission of patient-centered care and quality healthcare delivery.  Since our clinical decision support tools are first and foremost used by and designed by our own frontline staff, our culture of patient-centered, evidence-based care is a critical asset.  We’ve built our brand around being a trustworthy health institution which requires that our staff genuinely care for patients without ulterior motives such as profit maximization over patient needs.

In addition to these “superpowers,” we have been operating in Nairobi for more than 10 years.  In that time, we’ve built strong relationships with the Ministry of Health, the National Hospital Insurance Fund, local suppliers, insurance companies, community organizations, and educational institutions.  We have a mature understanding of the sector and we are well-positioned to build the adoption of CDSS tools locally.

Our solution has already achieved an impressive degree of scale. Our Clinical Decision Support System is used in nearly 1000 clinical encounters across Nairobi every single day.  Our data have demonstrated that we’ve dramatically improved the quality and value of care that our patients receive.  However, there are two major barriers we need to overcome to continue scaling this technology.

First, continually updating the technology, user interface, and data backend is an expensive endeavor.  Our shareholders and several grant partners have enabled us to get to this point, but we must continue to innovate.  We have a substantial backlog of improvements and design features that we would like to implement to improve the user experience, but we will require more funding to make some of those changes.

Second, as we look to implement improvements in our solution, we would greatly benefit from the technical expertise the Challenge could offer.  Primarily, we would like to be connected to experts in digital health product design and APIs for healthcare to ensure that we iterate on our solution with the best practices for the long term.  We have done 3-6 month engagements with experts before (including through Rippleworks) and we’ve found that process to be extremely fulfilling and helpful to our business goals.

Finally, we would like to help other healthcare provider organizations adopt CDS systems.  To do so, we need to demonstrate the value and impact of these systems through not only peer-reviewed academic papers, but also through blog posts, interviews, and more accessible media to catalyze the adoption of CDSS among providers in LMICs.  MIT researchers and thought leaders could really help our data come to life and catalyze change.

Penda’s approach to measuring and improving primary healthcare using a clinical decision support system is a massive leap forward for the quality of care in low and middle-income countries.  We are at an inflection point in primary care delivery in LMICs in which even low-resource settings have implemented simple EHR systems and are tracking patient care using digital tools.  3G network availability and low-cost devices like phones and tablets are more available than ever before, even in remote settings.  The transition that now needs to happen is to allow the newly available digital tools to improve the quality of care delivered at scale.

Although clinical decision support systems are used in other parts of the world, their impact on the quality of care has so far been limited (BMJ, 2020).  We have proposed that in order for CDS systems to realize their maximum value in terms of impact on the quality of care, they must be implemented in the right setting – namely, primary care in low and middle-income countries where baseline guideline adherence is low (Korom, 2020 and Korom, 2022).  What makes this approach truly innovative is how broadly it is deployed across more than 90% of patient visits in our primary care network.  This allows broad impact in terms of quality improvement, and it also facilitates direct quality measurement across the vast majority of clinical encounters.

We are confident that clinical decision support systems will be ubiquitous in primary care ten years from now.  Given the dramatic improvements that we have seen in the quality of care at Penda, we believe there is a need to accelerate the adoption of clinical decision support systems among primary healthcare providers in LMICs.  We have already seen several ways that Penda’s early adoption of CDS tools has been catalytic for the sector.  For example, local partners such as micro-insurers, have publicly recognized Penda’s leadership in clinical decision support with a national quality award, and have encouraged other providers to adopt similar approaches. Third-party audit organizations, such as SafeCare (PharmAccess Foundation) have commended Penda’s innovative approach to quality improvement through our CDS system.  As major stakeholders in the sector take note of the value our CDS tool brings to quality, other provider organizations will accelerate their transition.  Penda has already provided advice and guidance to other providers on how to implement such tools and we’ve agreed to open-source our CDS tools to other providers.

One additional step we would like to take in order to catalyze further adoption of CDS systems in our setting is to publish our findings in a peer-reviewed journal.  Our data can demonstrate clear improvements in the quality of care, and scientific publication will help bring legitimacy and credibility to our work.  We believe that scientific discussion of peer-reviewed findings will also serve as a catalyst for greater adoption.

• Penda Health’s vision is that everyone in Africa has healthcare they can trust. Our specific outcomes include:

1. To improve the quality of healthcare for underserved families in Kenya. We do this through a three-pronged approach of 1) training frontline staff using our e-learning platform; 2) standardizing clinical care using our CDS system described here, and 3) real-time measurement of the quality of care using our CDS system and feeding this back to frontline staff to create a virtuous cycle of quality improvement.

2. To increase access to quality healthcare.  Our high-volume, low-margin model allows us to provide primary healthcare to thousands of patients every day at a cost of USD10 per visit.  As we expand our physical network and awareness of our nationwide telemedicine platform, the access to quality healthcare will continue to grow exponentially.

3. To improve the patient experience of care.  Outstanding patient experience is what allows Penda to grow and succeed.  We continuously iterate on the patient experience of care by having a best-in-class customer service team.  Our approach ensures frontline staff get plenty of customer service training and are supported by managers who also deeply value the customer service experience.  Furthermore, we collect so much patient feedback that we are able to immediately and effectively address complaints as well as generate insights on internal customer satisfaction trends.

4. To change how primary healthcare is paid for.  We believe primary healthcare is best when paid for under some version of a value-based care contract, which could include subscription/membership models or outcome-based payments.  Particularly in low-resource markets, we have seen that fee-for-service models lead to patients forgoing high-value preventive care.  We are the national leader in Kenya in accelerating this transition by working directly with large employers to cover their employees with basic primary care services under capitation contracts.  We also work closely with insurance companies to expand micro-insurance coverage to emerging markets through low-cost, high-volume membership models.

• Number of uninsured patients accessing care at Penda:  Nearly 95% of Kenyans lack medical insurance.  These people are the most vulnerable in terms of accessing high-quality medical care.  By increasing the number of unique uninsured patients we serve, we are greatly expanding access to high-quality care.

• Percentage of clinical encounters at Penda that use a defined care pathway in our clinical decision support system:  When patients receive care supported by our tech-enabled decision support, we know they are receiving care in accordance with a vetted, evidence-based guideline that has been reviewed by our clinical team.  Currently, more than 90% of clinical encounters at Penda are supported by tech-enabled decision support.
• Percentage Guideline Adherence:  As described above, our CDS system enables us to have a real-time view of clinical guideline adherence across all patient encounters.  We aim for 90% guideline adherence, in accordance with other international leaders on quality improvement, to account for a small, but necessary clinical variation.

• Number of patients enrolled in a membership-based primary care model at Penda:  We know that primary care will improve faster if we can change how it is paid for.  We are the national leader in shifting patients from fee-for-service models to subscription-based models of primary care.

• Net Promoter Score:  We have been using Net Promoter Score for ten years to quantitatively and qualitatively track the patient experience of care.  With more than 1000 unique feedback points every month, we have an extremely detailed view of our patients’ experience of care at Penda.  (Current NPS = 72%).

Penda’s theory of change is a reaction to the fundamental injustice where Africa’s life expectancy is decades behind many other wealthier countries.  We believe that organizations like Penda can rapidly address this by ensuring the most impactful health interventions reach the mass market as quickly as possible hence our strict focus on primary healthcare. Numerous studies including a Primary Care report by WHO (2021) concur that resources deployed in the primary care setting are the most impactful in terms of outcomes achieved relative to dollars spent.  

Our theory of change was further tested and proved during COVID-19, when we managed to be the first and only private clinic chain to offer the vaccine free of charge to our patients directly in the communities where they live and work. Our patients were receiving the Pfizer and Moderna vaccines a mere six months after they were available in the United States.  

In our line of work, we see barriers to agency every single day.  Our patients care deeply about their health and the health of their families.  In many cases, they are very well informed about the need for various services and they are motivated to access them, but high-quality services are unfortunately out of reach for average Kenyans.  Our patients are painfully aware of the vicious cycle of poverty and poor health: Poor health impacts one’s income-generating activities, eating into their savings and often resulting in high debt levels.  On the other hand, good health preserves individual agency to generate income, spurring a positive cycle of health, wealth, and increasing agency.

Penda Health’s model and impact theory are the foundation of a high-quality, affordable and accessible healthcare system with the potential to be scaled across the country and continent. Our Blended Healthcare model which aims to give individuals better agency when it comes to their health and well-being, has three main components:

• The infrastructure: We have created a brick-and-mortar branch network of 19 physical Medical Centers that allows patients to walk in, any day of the week, to receive comprehensive and affordable outpatient care. 

• The model: We employ and enable mid-level clinical officers to provide high-quality and low-cost care.  Our training center and team conduct ongoing training for both our clinical and non-clinical staff. We invest in training our staff to deliver clinical quality in a friendly, reliable, and patient-centered experience. Patients also receive a follow-up phone call from a provider after their visit as we aim to provide an unparalleled personalized experience. 

• The technology: We have a fully-operational electronic medical record system that tracks patient data, a Clinical Decision Support Tool that ensures the standardized quality of care and achieves better health outcomes as it allows our providers to "get it right" every time. Our telemedicine system (fully equipped call center and our WhatsApp “Chat Na Penda”) allows our patients to access a variety of services at their fingertips. This has also made our services to be geographically borderless, beyond our current physical centers. The WhatsApp chat allows quick resolution of routine and common queries, increasing our communication efficiency and allowing the Call Center to focus more effort on patient follow-ups, and telemedicine consultations, among other services.

The core technology that powers our solution is a web application that interfaces with any outpatient electronic health record.  This system, which we developed jointly with a developer in India, can accept inputs in the form of patient concerns (e.g. “Cough”) or diagnoses (e.g. “Uncomplicated Malaria”); and return a list of clinical recommendations based on best practices for those conditions.  The recommendations could be diagnostic tests, medication recommendations, referrals, or even patient education materials.  

The web app connects with any outpatient electronic health record via APIs and serves as a modifiable database for clinicians who are moving through their typical workflow.  As the clinician progresses through the patient encounter, by entering a patient diagnosis, for example, the web app will return the relevant recommendations with an option to accept or reject those recommendations before they continue.  Since accepting the recommendation automatically populates the recommendation as an order in the EHR, following guideline-based care becomes the simplest “path of least resistance” for frontline clinicians.

On the back end, the accept/reject data is stored along with all other clinical data in a data warehouse.  This creates an extremely rich data set for frontline clinicians and organizational leaders to identify insights regarding outliers for guideline adherence as well as trends throughout the organization.  We also envision this data being useful for understanding patient response to treatment, and perhaps one day could be used to support clinical trials in LMICs.  Any data visualization tool, such as PowerBI, Tableau, Looker, or Google Analytics would be sufficient to create powerful dashboards to quantitatively measure the quality of primary care.

Being primarily text-based, this system is extremely light and adaptable for use in very low-resource settings.  It could be integrated with any outpatient EHR system that has fields for diagnosis, medications, etc.  We have seen a rapid explosion of basic outpatient EHRs in Kenya, many of which are device-agnostic and can run on 3G networks.  Some minor development work may be required for the native EHR to display the recommendations in the context of the standard workflow.

As described above, our Clinical Decision Support System offers guideline recommendations at the point of care for more than 90% of clinical encounters at Penda.  As the recommendations are offered, there is a single click (accept/reject) that the clinician must take before closing the visit.  When a recommendation is accepted, the recommendation automatically becomes part of the record, as a prescription, diagnostic test, referral, or patient education material.  When a recommendation is rejected, the clinician can simply proceed with their typical workflow.  The result is that providing guideline-based care becomes the simplest thing to do (“path of least resistance”).  Whether that path is taken or not is automatically recorded in a structured way as the clinician proceeds through their standard workflow.

Our clinicians also record some clinical data in a more traditional way using drop-downs or free text areas in order to capture certain parts of the patient history and their assessment and plan.

Clinicians at Penda have performance expectations that include providing high-quality medical care, including meeting an expected threshold of documentation quality.  We also routinely meet with outliers to understand why they are deviating from guidelines much more often than their peers.

Penda takes pride in not only having a female CEO but also over 67% of staff being women including women specialists in the medical field and over 50% of the executive team being women. Our female staff earn approximately 63% of Penda’s payroll.  Our goal as an institution is to continuously create pathways for career growth and leadership, invest heavily in staff training, and provide the tools and resources for staff to do their jobs well.  99% of our staff are Kenyan citizens and many of our staff are from and continue to live in the communities we serve. We hold progressive policies on diversity and gender mainstreaming and inclusion.

Penda’s business model is that of an innovative primary healthcare provider: We directly provide primary healthcare services to low-income families.  The vast majority of our patients pay cash out-of-pocket on a fee-for-service basis for whatever services they receive (consultation, lab, imaging, pharmacy, procedures, etc.).  We are working to shift more patients from a fee-for-service model to a subscription-based (capitation) model.  Whether fee-for-service or subscription, our business model requires considerable scale in order to earn a profit at the low margins we provide to our customers.  

Besides our B2C customers, we have a growing number of B2B customers through contracts with large employers.  In addition, more than 5% of our revenue now comes from patients covered by the largest government payer – National Hospital Insurance Fund (NHIF).  This segment is also growing, and is likely to be a substantial revenue source as the government further invests in UHC.

Our key customer and primary beneficiary is a low-income Kenyan seeking high-value healthcare.  We know that trustworthy options for our customers are limited, because it is extremely difficult to provide an amazing healthcare experience for less than 10 USD.  In order to properly satisfy our customers, we must:

• engage clients as valued customers with a strong customer service mindset
• provide appropriate, evidence-based healthcare
• keep wait times low (under 60 minutes on average door-to-door) 
• provide a variety of options for feedback, including phone, WhatsApp, and social media 
• have a physical clinic network within one bus ride of every Nairobi neighborhood
• maintain very low prices 
• be open with high service availability 12 to 24 hours per day, 365 days a year

Our patients have no end of frustration and disappointment with their past healthcare experiences, so it is very clear that there is a strong desire in the market for this sort of healthcare product.  Executing at this high level consistently is very challenging and is why this market gap exists.

Penda has cultivated deep relationships with our regular patients who appreciate the strong customer service experience and high-quality medical care at an affordable price. Not only do we have one of the highest NPS metrics in outpatient care in Kenya (72% against an industry average of -5%), but nearly 80% of our 1000 daily visits is from repeat patient! 

Penda’s most important customers are individual patients and their families through a B2C model. We also have small but growing customer segments in the B2B and B2G marketplace through our direct membership model with large employers, and our NHIF government contracts to provide care under the National system.  

Our market size is massive.  Since we are available to both uninsured patients (95% of patients in Kenya, just like the rest of the continent), as well as emerging insurance markets.  We serve both walk-in patients across all our 19 medical centers in three counties and we also provide care to thousands of virtual patients country-wide.  We are currently serving over 1000 patients daily, and we can grow to 4000 patients per day at our current capacity.  By expanding to other counties, and eventually countries in Africa, we believe our market size approaches 1 billion people. 

On key resources, the physical medical centres around Nairobi allow us to offer direct healthcare services to patients and families. This physical network is a key resource that has taken 10 years to build and now supports our blended (brick and click) healthcare model.  

Our electronic medical record (EMR) with Clinical Decision Support allows our providers to "get it right" every time. The data backend allows us to have detailed insights into our performance and operations which is a critical asset for a company of our scale and ambitions.

Our telemedicine system (fully equipped call center and our WhatsApp “Chat Na Penda”) allows our patients to access a variety of services remotely and extends our care model into people’s homes wherever they live in Kenya.

Our brand is a key resource.  Since we’ve been providing primary care in Nairobi for 10+ years, we are well known all over the city and have strong relationships with local partners, including NHIF, the Ministry of Health, insurance partners, and local community groups.

Penda is an omnichannel care delivery platform.  The oldest and largest channel is our network of brick-and-mortar clinics.  This is still the primary channel that most Kenyans use to access healthcare, and more importantly, it is a critical channel for providing many high-value services such as vaccinations, family planning, and emergency care. 

Our telemedicine platform is our newest and fastest-growing channel.  “Pigia Penda” (Call Penda) can be accessed by mobile phone or on WhatsApp.  These so-called “low-tech” forms of telemedicine are well suited to our market because people are most comfortable using these channels, they don’t require new app downloads or heavy installations, or new usernames and passwords, and they are light on data, which saves money for our patients.  The telemedicine platform provides remote consultation as well as home-based services including drug delivery, lab draws, and minor procedures for homebound patients.

Social media channels are critically important for driving patient awareness and traffic to Penda’s various channels. Penda uses Facebook, Twitter, and Instagram to reach out to patients and potential customers in Nairobi and beyond. 

We also consider B2B and B2B2C to be major customer acquisition channels.  Our corporate sales are growing rapidly and allow us to tap into large employer networks.  We also work closely with insurance companies to design new products for emerging consumers.

Penda’s cost structure can be broken down into 2 main sources of costs: Medical Centre costs and Back Office Costs. At the medical centers, the biggest costs in order are Labor (~35%), COGS - mostly drug and lab supply costs (~25%), and OpEx (rent, utilities, general supplies, etc. = ~15%). This allows the medical centers to earn approximately a 25% margin on their revenue. 

Coming to back office costs, the key drivers are quality improvement (clinical operations experts), IT (front-end and back-end software systems (EMR, ERP, email and collaboration tools, etc.); Finance (cash controls, credit management, especially insurance claim management), procurement and supply chain management, and external affairs (government relations).  

The vast bulk of Penda’s revenue comes directly from patient care operations.  About 80% of our patients pay with cash out of pocket, while the remaining 20% have some sort of medical insurance cover or third party payer, including the government’s NHIF.  In addition to revenue for patient care, Penda has raised a blend of equity, debt, and impact grants to allow us to scale our activities and maintain quality as we reach overall company-level profitability.

Since 2021, Penda’s network of branches now operates at a slight profit.  Our goal is to become fully profitable at the Company level based only on revenues generated from patient care, and we have a likely path to do so by 2023.  In the meantime, we raise a mix of equity investment and grant capital to support our efforts on quality and scale. 

• Revenue generated in 2021: 3.5M USD

• Projected revenue for 2022: 5M USD

• Convertible debt as of July 2022: 500,000 USD

• Recent Grants (last 12 months):

  • Pfizer (Global Health Innovation Grant): 100,000 USD – for work on antimicrobial stewardship using our CDSS

  • EnterpriseForDevelopment (EFD): 80,000 GBP – to expand our CDSS to include telemedicine

  • Phillips Foundation: 100,000 USD – to implement digital X-ray and point-of-care ultrasound

  • DEG/CDC: 100,000 USD – to develop an e-learning platform and training centre for frontline staff

  • Segal Family Foundation: 20,000 USD - to deliver Covid-19 vaccines in hard-to-reach communities

  • Dalberg Design: 10,000 USD – to test targeted outreach messages to encourage Covid-19 vaccine uptake in high-risk populations