Urgent care freelance Nurse dispatch services for uninsured

THE INFORMAL SECTOR LABOR FORCE IS EXCLUDED FROM UNIVERSAL HEALTH CARE. 

COMPRISED OF RURAL-URBAN INTERNALLY DISPLACED BLUE-COLLAR WORKERS, MARKET TRADERS, AND FARMERS, AN ESTIMATED WORKFORCE OF 15 MILLION PERSONS IN KENYA, INFORMAL SECTOR EMPLOYERS CAN'T AFFORD PRIVATE INSURANCE AND THE OUTPATIENT BENEFITS UNDER THE NATIONAL HEALTH INSURANCE FUND DO NOT CATER TO THEIR NEEDS, NOTABLY MENTAL HEALTH, ROUTINE CHECKS FOR OCCUPATIONAL DISEASE, AND ACCESS TO SAFE QUALITY MEDICINES.

Over 15 million people in Kenya, and  56% of the working population in sub-Saharan Africa, are informal workers. These are farmers, market traders, teachers, cab drivers, guards, house helps, waiters, tour guides, etc. Farmers and off-takers selling in markets for example are exposed to pesticides, fertilizers, and fine dust particles. They are at risk of respiratory and cardiovascular disease. Factory workers are at risk of musculoskeletal diseases due to repetitive movement. As residents of slum areas, they are exposed to common infections, especially sexually transmitted diseases. In April 2023, 48% of workers in a factory we screened were positive for urinary tract infections, of which 95% of the workers are women ages 21 to 54 years. The infectious disease burden among blue-collar workers is costly to them and the economy.

Their enrollment in the National Health Insurance Fund (NHIF) is below 5%. Less than 1% have done a medical checkup in their lives as annual fitness for work checks are not covered by employers or NHIF. Unaware of their health status they rely on curative services when severely ill hence the high rates of hospitalizations among blue-collar workers. Known barriers include long wait times, fear of discrimination, and discomfort when in large hospitals. Finding a reliable primary care doctor is complex and private insurance is too costly for organizations that employ casual workers.

Informal workers are internally displaced persons who have migrated from rural homesteads to urban cities in search of a job. They reside in low-cost housing estates and inner-city slums. Primary care is often accessed in tabletop one-person clinics in the slums that operate from 9 am to 5 PM, during which time most workers have left for work. Seeking quality care means time away from work. They lose an estimated $35 per day in business when sick. 

Constrained by the cost of care, blue-collar households in Africa incur undue financial burdens when sick. Common diseases are a major driver of poverty and preventable untimely death. The elderly who can't afford the health insurance premiums, including parents of blue-collar workers are also vulnerable. Once termed out of insurance offered by employers, they are left without cover. The local dispensaries & hospitals, mostly optimized for maternal and child health care, are ill-equipped to cater to their chronic diseases. Only one hospital could test for HBA1c (Pan Afr Med J. 2022; 43: 65). The informal sector and elderly thus lack access to quality diagnostics, a major disincentive to adopting the NHIF plans. 

A technology-enabled nationwide Urgent Care Nurse dispatch service coupled with a monthly pre-paid managed care plan that offers deep discounts for groups of workers (B2B2C) and covers in-home and in-workplace care for 25 common primary health needs for blue-collar workers, their households, and the elderly.

CheckUps is No. 1 in Urgent Care and dispatch medicine to informal sector organizations and their households. We are a hybrid brick-and-mortar and digital operation. 

CAPACITY: Located within Nairobi's largest industrial parks, our 4 urgent care centers offer walk-in services to factory workers. Workers located at home or in other areas are served at home or work by our main urgent care center equipped with a "Situation room" that is staffed by doctors and specialists who support inbound requests for care. 

DIGITAL SYSTEMS: Following the intake, doctors' orders from our in-house EMR are loaded into a web-based dispatch application. The case is then assigned to a dispatch nurse, lab tech, or medication delivery rider. The dispatch app platform allows for real-time visibility of orders, two-way conversations between patients and assigned staff, real-time visibility of the staff while in transit, billing details, and clinical orders or prescription details. Once the patient is served, the nurse fills in the details in the dispatch app based on a checklist for target conditions. The data feeds into the patient record in the EMR. Upon completion of the assigned tasks, the nurse is paid her fee for the service offered. 

NETWORK: This technology platform is a major disruptor in the market. It allows us to rapidly scale to both rural and urban areas with minimal overhead by recruiting FREELANCE nurses who are only paid per patient served. The dispatch software enables us to recruit, train and manage the dispatch of freelance nurses to homes or workplaces to enable us to reach clients within 30-60 mins. We reimburse nurses Ksh 300 per visit, hence they can earn a full nurse's salary by serving 4 patients a day, 25 days a week. This digitally enabled first-to-last mile distribution approach enables us to track operations, guarantee quality, and offer doctor-supported services in the home or workplace. Nurses can obtain electric bikes payable over 36 months from salary deductions.

MANAGED CARE PLAN: Our managed care plan helps customers and households save costs on the diagnosis and treatment and minimize lost productivity or business caused by HEALTH CONDITIONS THAT AFFECT WORK. 

With monthly payments of $5—$20, primary members get an annual checkup, 2-4 nurse visits per year, lab sample collection, and medication delivery to the home or workplace. Furthermore, the plan covers mental health support, learning disabilities support for school-aged kids, and chronic disease management for the elderly. These services are anchored around the social determinant of health and are neither covered by private insurance nor NHIF. We also offer family plans to cover households.

Persons with chronic disease, farmers, the elderly, teachers & pupils, market traders, and start-up companies save $500 to $1400 per year and avoid lost time away from work. 

Target market: Blue-collar workers are the backbone of the family and the economy in Kenya. These are farmers, teachers, waitresses, taxi drivers, and market trades. A day off work is more expensive than the cost of care. A sickness episode in their households for themselves, their child, or their elderly parent back home, means borrowing money. Blue-collar workers are affected by a trifecta - they can't afford private insurance, they can't afford quality private care; and lose wages when served in busy NHIF public hospitals because of long wait times.

Sickness = High cost of care + Lost wages = uncertain financial burden.

What happens when a worker gets sick while at work?

1. Take a time off from work (or disappear) for 2 – 3 days. Factories report 15-20% lost productivity due to sick-offs for common conditions.

2. Borrow money to pay for care. Microfinance loan data shows that 75% of defaults in payments are due to medical illness.

3. Unsure which clinic will give them good care. Clients are uncertain about which facilities have good labs and medicines. 17% of facilities are fully equipped with lab and diagnostic equipment. 40% of the medicines in the open market are counterfeit. A 2022 study in Muranga Kenya reported that "in the surveyed health-care centers, no hospital use electrogram and only one had troponin test. No hospital stocked Isosorbide dinitrate and Glicerine trinitrate to prevent chest pain in patients with a heart condition." Published online 2022 Oct 7. doi: 10.11604/pamj.2022.43.65.31347

4. Unsure which clinic is affordable. The prices of outpatient care vs quality vary greatly between public and private facilities and between the various levels of care. Knowing what is a fair price for quality is a major challenge for less educated segments of the population. This results in deferred care and avoidance of quality facilities. 

GOING to clinics is thus not convenient...

Long wait times… they lose 1-2 days of work.

Transport costs… 200 – 600 Ksh is spent on transport which adds to the cost of care. 

The actual cost of care is high. Labor costs are rising making access to doctors increasingly reserved for those with private insurance. 

Quality of medicines… poor among local chemists. Many small facilities rely on tier 3 suppliers and distributors. They settle for lower-quality medication to save on costs. 

NHIF outpatient cover is limited. Facilities accredited under the national health scheme receive $15 per member per quarter. These extremely low limits force facilities to offer basic nurse care and rapid tests and no medication to patients with NHIF cards. 

Hence, Blue-collar workers' households are affected by poor customer service, high cost and uncertain quality, non-inclusive NHIF benefits, the significant cost of transport, and lost business due to long wait times. A sickness episode is a cause of lost wages, burrowing of money, and other financial burdens.

CHECKUPS HAS HONED A CUSTOMER-CENTERED APPROACH OVER THE PAST 10 YEARS WHICH GUIDES OUR PRODUCT DEVELOPMENT AND COMMERCIALIZATION CYCLES FROM INCEPTION TO DELIVERY. 

CheckUps started as a community-based initiative branded the 2020 MicroClinic Initiative in 2011. Our goal was to increase access to antenatal care and skilled deliveries. Through an interactive design thinking process, the target communities helped us to identify an invisible gap that prevented women from going to the clinics when in labor. The lack of clothing for the babies engendered anxiety, shame, and a sense of discomfort. We developed an intervention that was simple. Recycled t-shirts donated to the organization were converted into onesies, socks, hats, and blankets for newborns. We promised free clothing to women who were compliant with antenatal care - Operation Onesie. Within 5 years, we had shifted the skilled delivery rates from below 17% to 64%, and zero maternal mortality in the 30 communities we served. https://www.mightycause.com/or...We learned from this experience that innovations that focus on CUSTOMER EXPERIENCE have a place in the market. 

This project enabled us to map out last-mile medication delivery systems and last-mile access to laboratory tests and diagnostics in 2015. Price hikes in community pharmacies, solely driven by reduced stock levels of drugs in the public clinics, were standard practice in each of the 30 communities we visited. Under a new company, MicroClinic Technologies, we proceeded to develop the first electronic medical record system, branded ZiDi, to support real-time visibility of stock levels at the national level in Kenya, a solution featured in a 2015 Harvard Case Review - https://store.hbr.org/product/.... This technology is what we use to date for our EMR and integrates with our Dispatch app for home service delivery. Thus our system is compliant with National Health Information standards. The platform was for clinics and hospitals and county health officials. Uptake was constrained by the absence of incentives needed to drive provider uptake and adoption of the platform.

In 2017, we pivoted to a digital app to help clients directly access information on available clinics, labs, and pharmacies next door. The platform was branded iSikCure. After, 18,000 downloads, we pulled down the platform as the cost of maintenance of a D2C app far exceeded the return or cost savings to clients. Lesson: Digital first health apps are expensive and not sustainable with low-cost services and generic drugs. https://youtu.be/6ci0nqGhYhc 

In 2018, we pivoted our strategy to a brick-and-mortar operation under the CheckUps brand targeting underserved communities through industrial parks, and in 2022 launched our D2C dispatch network to reach farmers and market traders who are dispersed in low-density settings or high-density markets, respectively. This approach has enabled us to scale to over 280,000 visits, 46% of which were virtual or home-based in 2022, thanks to the market shift in-home care due to COVID-19. CheckUps is now known as a brand that helps organizations control the cost of outpatient care. 

Experts from the insurance industry then helped us design the managed care plan. 

OUR CURRENT B2B2C APPROACH HAS ENABLED US TO REACH CLOSE TO 300,000 LIVES, ABOUT 1% OF THE SERVICEABLE OBTAINABLE MARKET. 

We currently contract our services to 18 health insurance companies in Kenya and six in South Sudan through which we have served over 250 corporations to date. 

We also contract directly with 58 companies located in the Export processing zone and employ a combined total of over 37,000 factory workers. 

We have partnered with 1 tea factory to reach 10,000 farmers. We have also partnered with a food aggregator to reach 3,000 farmers. We are 60% in the customer conversion cycle as lots of buy-ins are needed with the farmers' cooperatives, which is the gateway to the small-holder farmers we seek to reach. 

In aggregate, we have served over 290,000 clients from 2018 to date. 

Market opportunity:

o   Total addressable market (TAM): The total addressable segment is 47% of the population in Kenya, of which 51% are women, and all uninsured, who spend a total of $1.8 to $2 billion dollars on out-of-pocket health care expenses.

o   Serviceable addressable market (SAM): We will target households in the 10 most populous counties, equivalent to 50% of the population, i.e., approximately $1 billion in value.

o   Serviceable obtainable market (SOM): Households of small-holder farmers, and market traders, who earn a target $10 per day are 40% of the population, hence an obtainable market of $400 million. 

o   Projected 5-year achievable market: With 300 nurses serving 4 households per day, we can reach 240,000 patients in 200 - 300 days; i.e., 1 million lives in 5 years, equivalent to $50 million in gross revenue.

IMPROVING HEALTH ACCESS FOR DISPLACED POPULATIONS REQUIRES INTEGRATED SOLUTIONS THAT COMBINE HIGH-THROUGHPUT CENTRALIZED OPERATIONS that drive the supply chain + COST-EFFECTIVE DISTRIBUTION NETWORKS to ensure optimal response times + HEALTH FINANCING that demonstrates savings over the status quo. 

With scale, the technology systems we have developed would need to be progressively optimized using blockchain, AI, and fintech solutions. We are thus enthusiastically looking forward to joining the SOLVE ecosystem to enable us to leverage peer innovations that can enable us to scale without compromising quality or favoring revenue leakages. 

We also seek to contribute to the SOLVE ecosystem by virtue of the huge data we have collected that could be adopted by our partners to develop point-of-care solutions for the African market. 

Lastly, being an innovation that is at the forefront of shaping private sector innovations in Universal Health Care, we would like to lean on the SOLVE network to develop Impact monitoring and evaluation systems that will demonstrate our impact on Blue Collar workers. We anticipate impact at the multiple levels 

1.     Informal workers and farmers lose an estimated $35 to $50 per day of business when sick and borrow $20 per illness episode. Our subscription dispatch model should save each household an estimated $250 to $300 per year in lost wages. Hence, reaching 240,000 informal workers will prevent close to $60 million in lost wages over a year.

2.     School-based services will prevent a projected 18,000 kids from missing school per year. We expect most of the school cases to be young girls seeking care for reproductive health services, notably severe menstrual pains and period problems (irregular bleeding, etc.) and mental health conditions. We thus expect to impact learning for children of blue-collar workers.

3.     Increase access to WHO-recommended childhood vaccines for a minimum of 1000 children. More convenient distribution should favor access to vaccines at home.

4.     Initiate treatment and monitoring for a target of 72,000 chronic patients, especially elderly persons. We will promote screening for prostate cancer in men over 40, and breast and cervical cancer in women over 35 years.

Robust evaluation tools such as those developed at the Abdul Latif Jameel Poverty Action Lab (J-PAL)  would be needed to demonstrate our impact on poverty.

Offering CONVENIENCE, QUALITY, and AFFORDABLE care for informal workers is the next frontier for UHC. 

Without access to convenient, quality, and affordable care, farmers and other dispersed workers will be excluded from the national Universal health care agenda. 

Public & private health facilities with limited diagnostic capacity are unsuitable for them due to long wait times. Only 17% of the 6000-plus clinics in Kenya are fully equipped requiring hoping to different locations during an illness episode. Private neighborhood mini-clinics are either too expensive when properly staffed and equipped, or poorly staffed. The national hospital insurance fund (NHIF) which many informal workers like farmers are yet to subscribe to because of limited benefits which prevents them from seeking care in places with quality diagnosis and medicines. The default option is self-medicating or traveling far and losing business. With Universal Health Care defined as the “equitable access to quality health care services without an undue economic burden or loss,” the Government of Kenya is also seeking innovations that promote access to NHIF-subsidized services in a manner that also minimizes economic losses for the hustling low-to-middle income household, of which smallholder farmers form the majority.

Our approach to promoting public health and access to quality healthcare, particularly in underserved populations, is novel in that it combines telehealth, tech-enabled nurse dispatch services, digitized distribution of medicines, labs, and diagnostic services, and health financing services to offer convenient, affordable and quality care to the households that drive the economy.

IMPACT  BY COVERING DISEASES THAT ARE UNINSURABLE YET AFFECT WORK AND PRODUCTIVITY OF BLUE COLLAR WORKERS.

This project will help with the early identification and treatment of respiratory disease, hypertension, diabetes, gastroenteritis, urinary tract infections, mental health disorders, etc. which account for 80% of outpatient visits. 25% of outpatient clients have a mental health disorder with no access to a counselor. Women can't get antenatal care at home and can lose work when pregnant. Children would not have to be sent home when sick. Too many girls miss school because of painful periods for lack of proper care. Women members can send us to administer vaccines to their 0-5-year-olds without having to miss work. Elderly persons many of whom are small-holder farmers can be monitored for hypertension, diabetes, and arthritis in the home. Drivers and security guards get access to vision and wellness checks at the bus station. Traders get lab tests and medication delivered to their market stalls. Our project will affect lives, households, businesses, and the health ecosystem by shifting primary/family care to where people spend their time during business hours and away from the hospital.

Impact outcomes measures:

1.     Informal workers and farmers lose an estimated $35 to $50 per day of business when sick and borrow $20 per illness episode. Our subscription dispatch model saves each household an estimated $250 to $300 per year in lost wages. Hence, reaching 240,000 informal workers will prevent close to $60 million in lost wages over a year.

2.     School-based services will prevent a projected 18,000 kids from missing school per year. We expect most of the school cases to be young girls seeking care for reproductive health services, notably severe menstrual pains and period problems (irregular bleeding, etc.).

3.     Increase access to WHO-recommended childhood vaccines for a minimum of 1000 children.

4.     Initiate treatment and monitoring for a target of 72,000 chronic patients, especially elderly persons. We will promote screening for prostate cancer in men over 40, and breast and cervical cancer in women over 35 years.

How:

Short-term outcomes:

1.     Recruit and train 300 nurses in 10 counties

2.     Establish MoUs with farmers’ cooperatives in the target communities as anchor partners.

3.     Implement an evaluation and monitoring system for the freelance network.

Long-term outcomes:

1.     Reach 240,000 lives within 1 year. Each nurse would be expected to serve a target of 4 patients per day.

2.     Reach 3000 farmers in Yr-1. 10% of nurses (30) will be recruited to target 100 farms.

3.     Reach 30 markets in Yr-1. 20% of nurses (60) will be recruited to target 30 markets. Each market is expected to yield over 500 lives.

4.     Reach 60 schools in Yr-1. 20% of nurses (60) will be recruited to target 60 schools. Each school is expected to yield over 300 illness episodes per year (an avg. of 1-2 per day).

5.     Reach homes to serve women, children, and parents - 50% of the nurse will be distributed in specific catchment areas based on patient demand.

Capacity metrics

Number of Urgent Care & Dispatch Hubs - 5

Number of mobile clinics - 1

Total number of lives reached - 299,876

Total Savings per 100,000 orders - estimated at 1,000,000

Operations data:

Average delivery time: 2.55 hrs

Average patients per nurse per month - 300

Average patients per doctor per month - 700

Margins per visit (Non pharmacy)

Margins per visit (pharmacy)

Financial metrics

Revenue from Pre-employment tests

Revenue from urgent care and dispatch services

Revenue from annual checks and subscriptions

Clinical metrics

Acute case volume

Chronic case volume

Mental health case volume.

Each nurse trained and equipped for an estimated $250 will be able to respond to an average of 4 calls per day from her/his catchment area, which will in turn increase access to care for over 800 cases per year per nurse, which will, in turn, save lost wages and also lower the cost of care for households with chronic conditions and common outpatient conditions. 

Furthermore, a great experience with the subscription will serve as a gateway for families to invest further in private or public health insurance, in keeping with the Current Administration’s health agenda. Our goal is to achieve 5% to 10% more enrollment in NHIF in target communities.

We operate a significant technology stack:

1. Web portal for member enrollment and payment. We have partnered with a 3rd party provider for partial payment management called m-Tek. With m-Tek, clients can pay in installments.

2. EMR that tracks patient records, billing, and patient scheduling.

3. Dispatch app and monitoring dash board to track orders from the customer care service support center down to the delivery of care at the patient's home. 

4. Digital software for remote transmission of medical data.