Curafa Franchise Platform

Delivering high quality primary healthcare is a major challenge in developing countries and low resource communities. For the impoverished, their options when they become ill are limited: either receive poor quality healthcare that can worsen conditions, go into debt to access quality care, or spend an entire day waiting in a crowded public facility hoping to be seen.

Increasing the accessibility of healthcare alone, however, will not completely solve the issue. A systematic analysis of excess deaths in low- and middle-income countries published in the Lancet found that 5.7 million people die in low and middle income countries from poor quality healthcare – that is more than the number of preventable deaths from people not using healthcare at all. This remarkable study drives home the point that investments in healthcare are not enough, and poor quality is the silent killer in global health.

The COVID-19 pandemic is only compounding this issue, as a result of the health and economic challenges it brought, putting a strain on Government health expenditures which are projected to have a slow return to pre pandemic levels. 

Delivering quality healthcare is difficult for the average frontline health worker: 

• Staying on top of fast changing guidelines and meeting regulatory operational and quality standards in order to integrate with public healthcare systems.

• Difficulties in demand forecasting (planning how much medication you will need), difficulties finding affordable and quality medication to purchase, and a lack of working capital available to purchase medication and supplies for your clinic.

• Limited ability to invest in education and awareness for non-acute care, for example screening for cardiovascular disease.

• Low margins and therefore low incentives for providing comprehensive family care including family planning, immunizations, cancer screenings and non-communicable disease care.   

• There is a gaggle of apps to use to check symptoms, record information or manage your inventory but no comprehensive system to get the support you need to run your business and also manage patient care.

• Difficulty tracking and maintaining patients. 

“Indeed, the challenge before us is how to build and retain the PHC workforce with the right skills mix; to organize their care environment; and to ensure that they are well resourced so that the services they provide are of the highest quality, comprehensive, coordinated, and integrated across all levels of care, yet affordable and sustainable.” 

- The World Bank, Walking the Talk 

We believe that comprehensively solving the challenge in this World Bank quote is the challenge of our generation. Access Afya’s solution is a franchise platform that lowers the cost of primary healthcare through efficient, smart healthcare planning and improves quality of care for patients by giving clinical officers and nurses the comprehensive tools that they need to collect and manage data and run their business supported by a central multidisciplinary team. 

No one else is doing this comprehensively for primary health care on a large scale. We have built this network out to serve over 100,000 unique patients and are poised for scale.

Sources:

Walking the Talk : Reimagining Primary Health Care After COVID-19, https://openknowledge.worldban...

Access Afya (AA) has developed a physical and digital healthcare network utilizing asset-light micro-clinics, telemedicine, patient health data, and trustworthy pharmacies to engage patients throughout their healthcare journey, from diagnosis to treatment. 

Core to our model is our Franchise Platform, a combination of health technology, training, analytics and support to help new and existing clinicians and their teams improve quality and performance. This is novel in its scope, provides actionable data that is being used daily and monthly by dozens of care teams, and was designed with and for Kenyan clinicians over the last decade. 

A Patient Journey - How it works 

• The AA patient journey begins with our Community Health Agents (Community Health Workers with additional AA training) using our Mobile Afya Screening Tool to give health assessments and tips to community members. This tool examines a range of health risks and questions, and syncs data centrally. The app supports patient referral into our physical care network, backstopped by customer care when patients get stuck. Clinics offer: chronic care, lab testing, immunizations, pre- and post-natal care, first aid, and other general outpatient services, all at a price point ($3-5) 2-4 times lower than other healthcare companies serving low-income markets.

• AA clinics use patient management software to analyze health data from biometrics to demographics, all of which help our clinicians make accurate, informed decisions on treatment options.

• Following treatment, our patients continue to manage their health with mDaktari, a mobile clinic platform that provides teleconsultations, prescriptions, lab referrals, and health coaching over the phone. This is available through a progressive web application, on the Safaricom mini-application and over USSD for those without smartphones or data bundles. AA also offers a variety of financing options, such as microinsurance plans like M-TIBA, to ensure all patients can receive the healthcare they need regardless of cost.

• Our AfyaScore product aggregates over 150 indicators of quality such as essential drug availability, equipment availability and use, vaccination quality and selected indicators such as if blood pressure was measured for all pregnant women. This data provides relevant and focused continuous performance improvement.

From start to finish, AA is providing a convenient, affordable, reliable, and high-quality healthcare service for those who need it most.

Actionable Data and Insights 

Access Afya has combined: 

• Robust standardization: over ten years and hundreds of thousands of visits, what should be happening in each clinical encounter.

• Robust training and follow-on support, so that every health worker understands how to meet standards.

• Robust digital tracking, through novel data sources including encounter data (input by health workers – most health systems have this), patient reported data (input by patients themselves via SMS including health outcomes, satisfaction and other survey data), observational data (input by auditors and quality managers) and operational data such as images from security cameras or biometrics logins. 

This combination is unique and powerful.

Information from AfyaSmart, our core suite of tech products managing quality, is reviewed monthly and acted on by compliance managers and  franchisees to improve clinic metrics. 

The data is also reported to sub-county health teams contributing to aggregation of county  population health information. It can also be selectively and safely shared with other partners, like during the pandemic when we used our information to help provide emergency cash transfers to our highest risk patients. 

Empowering Health Workers 

“Indeed, the challenge before us is how to build and retain the PHC workforce with the right skills mix; to organize their care environment; and to ensure that they are well resourced so that the services they provide are of the highest quality, comprehensive, coordinated, and integrated across all levels of care, yet affordable and sustainable.” 

Quality care cannot exist without a supported and motivated healthcare workforce. Let’s look back at this quote, and how our platform systematically solves this challenge for the poorest populations in Kenya. 

• Building the PHC workforce, through Access Afya Academy, which is readily available for all users of our franchise platform. 

• Retaining the PHC workforce through meaningful employment, with the franchise platform offering them the opportunity to both earn a living and make an impact in their community. 

• A well resourced PHC workforce, through a standardized clinic in a box setup including rapid and point of care lab tests, start-up medications and working capital loans for restocking.

• Coordinated and integrated primary healthcare, through a networked chain of franchise primary healthcare centers, with centralized data management and virtual and physical escalation. 

• Affordable and sustainable care is possible through a scalable franchise clinic platform, reducing overheads for each clinic and enabling economies of scale.

Over 8 million Kenyans live in informal settlements and struggle to find affordable, quality healthcare. These are the ultimate beneficiaries of the Curafa Franchise Platform. 

• Access: Our target market takes up to 8 hours to visit a clinic. Clinics are overcrowded because Nairobi has just 26% of the facilities recommended by the WHO. These are concentrated towards the middle and the top of the income pyramid. 
• Affordability - Cost to visit private clinic even for simple ails can cost up to 8 times average daily wages of $3.50.
• Quality - In Nairobi alone, 34% of private clinics are informal and illegal, and at public hospitals, 48% of stock is typically unavailable.

For our end beneficiaries, we make healthcare accessible (open 7 days a week, available online, over the phone and in person, located in the vast slums where the majority of urban Kenyans live), affordable (66% less costly than other clinics trying to serve low-income markets) and effective (99% stock availability rate; 90th percentile for quality healthcare in Kenya, 98% of patients feel better within two days of a visit). 

The primary users of our solution are our franchise clinic operators, who are usually Kenyan Clinical Officers. This is a large market that needs support:

• 55% of Kenya's 13,941 registered health facilities are run by the private sector.
• 45% of primary care facilities are run as individual private practices.

Our target franchisees Clinical Officers and Nurses are ideal providers for comprehensive primary care under the scope of their license.  

• Of the 21,000 Clinical Officers currently registered in Kenya.
  • 6,000 are working with the public sector
  • 5,000 are working in private practice
  • 10,000 are unemployed
  • There is a shortage of healthcare workers relative to WHO standards, a shortage of care provision, and yet we have almost as many Clinicians out of work as we have working.
• Of the 58,000 registered nurses in Kenya, at least 5,000 are also unemployed. 

For our users, we take the hassle out of opening and running your own clinic, ensuring a seamless, standardized, high-quality experience each step of the way.

73% of our franchisees came to us to work for themselves: “I chose to be a franchisee because I want to be my own boss and work for myself” 

55% said that they wanted to leverage our central systems and expertise: “I was alone in the past, I was not able to put good accountability, HR systems, monitoring & evaluation and accounting systems” 

Sources: 

Kenya Union of Clinical Officers 2019 (https://kuco.or.ke/)

https://www.the-star.co.ke/new...

Access Afya has served over >390,000 patients physically and over 8,500 digitally and grown its presence to 12 sites in 4 counties in Kenya. 

Dr. Daphne Ngunjiri, our CEO, is a physician, has worked in the public and private sectors, has seen the problems from the inside, and believes AA is the solution. Her background combines medicine with health technology (having worked at one of Kenya’s first telemed start-ups) and business (through her Executive MBA in Healthcare Management). She works alongside Ruth Kimama, Chief of Staff with a background in sanitation franchising, and Estella Wachira, our Deputy Ops Manager with a background in nursing and healthcare operations.

Our management team is supported by young, bright Kenyans with backgrounds in nursing, informatics, finance and more. Our team is user centric - our tech is built from operational experience in the healthcare sector, and we are our own first customer.

We have spent a decade on this model, are a women-led, Kenyan team based in Nairobi, and have ~⅓ of our team coming from the informal settlements where we work. Our franchise model brings us even closer to our communities as we scale: with this platform, local clinicians and entrepreneurs can run a clinic in their communities, localizing the marketing and education, service mix and even pricing to their community’s needs. 50% of our franchisees are female (higher than the Kenyan average for small business ownership).

Our patients are involved in the continuous design of our model. 

Satisfaction surveys are automatically sent over text message to each new patient the day after their first visit. Anyone not satisfied receives a follow-up call from our customer care and all negative feedback is carefully compiled and scrutinized each month in order to see how we are able to improve. Health outcome surveys are also sent to all patients who come into an Access Afya clinic feeling sick, and for the 3% who respond that they are not feeling better, they are followed up with until they are better or need to be referred to higher care. Finally, a random sample of 10% of patients who do not respond to our text messages are called monthly so that we can chat with them about their experience at our clinic, their health outcomes, and any other of our programs we want feedback on. Last year our team won an award for the SME with the Best Customer Experience from the Kenyan Chamber of Commerce and this year Customer360 Africa named us the most Customer Centric Organization.

All of this information supports our team to use a human centered design methodology where ideas are planned, launched, quickly reviewed, and improved. Our innovation culture prioritizes feedback and continuous improvement.

We have experience executing and scaling up quality care programs with partners. AA was selected as a Solver Team for the Frontlines of Health Challenge in 2018, where we presented our Akiba ya Roho model. This approach to noncommunicable disease (NCD) management used a digital and physical model resulting in a 10x increase in people screened for diabetes and hypertension and converted to care in the last 4 years. This integrated awareness screening and management model has led to 90% adherence to NCD visits across the network and over 70% our hypertensive patients achieve blood pressure control compared to 33% in this study in a tertiary hospital in Kenya.

Quality is our core focus. We have moved intentionally and sometimes slowly to get this right. We have perfected a quality system used by 14 healthcare providers and which has  supported over 390k healthcare visits.

We are ready to grow this system, and the financial support and recognition from this prize will help us expand our platform, doubling our reach over the next 12 months, and attract new partners.

Financial Risk- AA needs a significant amount of capital to scale a low-margin, mass market business for the base of the pyramid – aprox 6 million over the next 5 years for a regional network in over 100 clinics and >130k monthly visits.

Mitigation: AA is raising a Series A using blended financing. We are already working impact debt, equity and philanthropic funders including Roots of Impact and others. This prize would make a meaningful contribution to the next funding round, focused on expanding our platform and doubling our reach over the next 12 months.

Technical Risk- AA needs to continue to develop its franchise platform, adding additional data linkages from primary sources and continuing to upskill its team in a competitive technical hiring environment.

Mitigation: We are focused on hiring and upskilling of our development team to achieve the following milestones: 

• Improve analytics for key data users primarily healthcare worker franchisee views and central support teams

• Migration to a cloud based platform

This technical work is being supported by a strong corporate partner and the World Economic Forum Technology Pioneers program. We would love to benefit from additional resources and mentorship, including support attracting talent.

• Leverages existing and underused healthcare infrastructure: 55% of healthcare facilities in Kenya are private sector, 45% of primary care facilities are run by single operators, and almost half of Clinical Officers are unemployed. Our model provides the only comprehensive solution to help existing clinics improve, and to help expand quality health access through an entrepreneurial model for unemployed health workers.
  

• Sustainable model: In contrast to not-for-profit fractional franchising, 7/7 clinics that were using our franchise clinic platform last year were able to make a profit.

• Patient focused - AfyaScore uses NPS and outcomes indicators as measures of quality, and mDaktari makes it easy to text, call and chat with patients between visits. 

• Comprehensive - data is used to identify training gaps across patient care and operational delivery, and to direct healthcare workers to relevant training.
  

• Effective: Already, we are in the 90th percentile quality rank in Kenya serving the poorest population in Nairobi.

Over the next year, we are doubling the size of our network through the expansion of the franchise platform in Kenya. We are doing this through a Series A blended raise, with our next dozen locations selected and ready to rollout.

Next Five Years:

• Access: 1.5 million patient served through expansion in 136 locations and through online care.

• Quality: 90% average score maintained on Afya Score through continuous performance improvement and training of health workers. 

The rapid growth over the next five years is possible through an evolution of franchise methods, from individual clinics to multi-unit operators (50% of our current franchisees would like to run an additional clinic) to regional and then master franchising. 

Access: as we grow, our expansion algorithm prioritizes communities with a facility to provider ratio of >10,000 meaning that we are entering places with an under provision of care. We look daily, monthly and quarterly at our increase in people served and aim to reach 1.5million people served by 2026.  

Quality: This is the heart of Access Afya, and of the Curafa franchise solution. AfyaScore is a custom app and analytics product, which pulls together operational data, clinical quality data, and customer data to give each clinic a score allowing the company to know precisely in which areas the clinics are doing well and in which areas they need improvement. AfyaScore covers essential healthcare quality metrics such as stock availability (currently averaging 98%), patient reported outcomes (98%), adherence to antenatal care protocol (94%), Net Promoter Score (68) and around 150 other data points.

Affordability: Bi-annually, we survey all facilities within a 2km radius of a clinic and calculate the price of services. Currently patients spend 66% less than they would at neighboring clinics.

Access Afya’s vision for the future of healthcare in Africa is a system which prioritizes preventative care, rather than reactive care, and uses technology to leapfrog shortfalls of the current system - making healthcare more accessible, cheaper, and improving people’s health.

Patients will be able to have consultations with clinicians over their phone, take risk assessments via online apps for chronic illnesses like hypertension and diabetes, and be able to manage these illnesses virtually as well. Physical clinics will also play a part, and will be run by franchise owners from the very communities where they operate. These hyper-localized clinics will not only provide convenient and cheap healthcare for their communities, but also quality healthcare guaranteeing good diagnostics and reliable medicine.

Our core technology is a mix of existing software and customized software, woven together into a novel business model and analytics platform.

Our HealthCRM is our custom and core analytics tool, analyzing data on how patients move through their care pathways, and enabling us to nudge behavior and follow-up.

We onboard our franchisees with Access Afya Academy, build on open source tools, this platform also supports continuous learning for our primary care workers.

Patient SMS surveys, appointment reminders and outcomes checks are a combined technique, leverage Infobips' software, and also custom code to trigger the right type of follow-up at the right time.

Also included in our healthcare platform is our virtual clinic, mDaktari, (http://mdaktari.accessafya.com... -- there are concessionary rates for clinic patients), an electronic medical record, supply chain management software, asset management tools and a screening application built for outreach.

The combination of standardized expectations, solid training and automated backend workflows can achieve incredible results.

In 2021, new franchise clinics were assigning follow-up visits to less than half of expected patients at an unsustainable cost: 

After the full implementation of our program, patients with follow-ups have almost doubled and the cost of follow-up are falling. 

We are doing this across 150 data points, and the improvement in follow-up visits are just one of many success stories that we can achieve with a comprehensive and supportive system.

Encounter data on screening, risk assessment and awareness is collected by community health workers on Mobile Afya, the virtual clinic, or directly input by our customers themselves on their mobile phones. Community health workers’ mediated interactions bridge the digital literacy gap  introducing the use and awareness  of digital health access to the community. Increasingly users themselves become aware of digital health services and interact with the digital tools independently lowering the cost of implementation. 

In physical clinics, EMR (Electronic Management System) collects and records patient registration information such as demographic data - residence, age, employment status – as well as clinical care records. The inputs are standardized and mapped to national and global standards to provide decision support in clinical management and analytics to drive improvements. Data is collected by both registration clerks and clinicians providing care as they interact with the patient, and they receive direct feedback on a regular basis about the quality, performance and insights from that data to drive service and business improvements.

Patient feedback on outcomes and satisfaction are collected via a communication platform, Infobip. The communication platform integrates with primary data sources to trigger messaging directly to patients with a focus on patient surveys on satisfaction, health outcomes and appointment reminders to care. Thereafter the data is input by patients responding on their mobile phones and by patient engagement teams who follow up with patients; based on patient feedback the teams initiate appropriate responses to patients and care teams.

With the exception of its founder, Access Afya prides itself on being an entirely Kenyan run company. The Kenyan management team all have stock in the company. Founded by a woman, and having a workforce that is 60% female, the Access Afya team of 62 members also consists of a diverse array of individuals representing different economic backgrounds, past experiences, and Kenya’s different tribes.

One-third of Access Afya’s team are recruited directly from the slums in which Access Afya works. This not only provides jobs to  those from the local communities, but this is done due to the belief that those living in the communities have the knowledge needed on how best to serve them. 

One area where we work to create empathy is between HQ functions - such as tech and finance - with our frontline teams. Pre-covid, we created a “Day in their Shoes” program where all HQ team members worked side by side with our Clinic Assistants and interacted with our patients for a full shift each year. We also hold corporate volunteering events so that those at our office can get to know our communities better by picking up trash, or handing out clothes after a fire.

The majority of Access Afya’s patients are also female, or children, and come from some of Nairobi’s most marginalized communities. To reach our patients, we engage and pay a network of 50 community health workers in screening and community education. They help us craft our messages and give us blunt feedback on our product plans and pricing. 

Access Afya’s first step is to get the right people in the room by hiring Kenyans from diverse technical backgrounds including people from their patient population. 

On this foundation AA has built a flat organization that strives to create a strong alignment on company strategy and values with semi-autonomous teams able to collaborate and make day to day decisions to achieve the organization’s goals. To improve their ability to hear everyone’s voice and invest in the next generation of leaders, Access Afya has engaged two executive level volunteers, including a current leadership coach, to reflect on and improve how the organization creates alignment, develops its team and empowers people to autonomously work towards goals. 

AA has created a few rituals to solicit continuous feedback. Annually, the organization plays a game called “Start, Stop Continue” where every single team member from the motorcycle rider to the CEO lists things that they wish AA did, that they want AA to stop and that they love about the company. The exercise has led to surprising shifts in strategy, and ideas that are not immediately implemented are transparently tracked so that people can see updates on why something might continue, even if one person wanted it stopped. In addition, quarterly anonymous surveys are sent to all staff to keep a pulse on team opinions, needs and satisfaction.

The reality is that AA is building products and services for the base of the pyramid so it must constantly put the patient in the room when making decisions. As a social business, they ask  patients to part with hard earned money for quality service, which will only happen if the business performs exactly in line with what people want and need.

We serve low- income earners up to 2x above the poverty line with affordable and accessible high-quality care at a price point of $3-5 for an in clinic visit. 

The model is scaled through franchising to local clinical officers. To join/grow the network of clinics, franchisees pay an initial license fee of $3,000 and monthly royalties as a percentage of revenues.

Access Afya has built a sustainable model for healthcare. With all our franchise sites with quality over 90% on indicators, and with proven unit economics at breakeven, we aim to start to scale this.  Access Afya also aims to commercialize custom technology that drives this impact to other primary care providers outside our network. The revenue model for Access Afya comes from three business lines of Franchise Clinics, SaaS and Analytics and Telemedicine. Franchise revenue is driven by franchise fees, including licensing fees and royalties, B2B revenue for tech solutions. Access Afya is  projected to be EBITDA positive by 2025.  The levers to deepen sustainability will be through health financing. 

Unit Economics: Access Afya digital and physical models are financially sustainable. Today, physical franchise clinics operate at an average net profit margin of 20%. Franchisees pay an initial licensing fee of $3,000 to Access Afya to join the network and franchise fees as a percentage of sales monthly. As the model expands, these margins go toward covering central costs. National Health Insurance funding currently contributes 30% revenue in profits to the business and is expected to grow with each new location.

Full financial Sustainability: Access Afya is raising a Series A to capitalize growth, tech improvements and marketing till breakeven in 2025. Revenue projections of $3.3m are expected through this growth plan in the next 3 years. Access Afya has been selected and is eligible for Roots Of Impact Social Impact Incentive (SIINC) of up to $300,000 for impact achieved over the next 2 years.

Last year our franchise owners earned 27% more than the private sector average wage for clinical officers. 

High quality, consistent, low cost healthcare makes for a good business model.