ReaMedica Locus

Vulnerable populations receive antenatal care in a scattershot manner.  Achieving an integrated model of antenatal care requires rethinking of how services are offered, accessed and sustained both clinically and financially.  The ReaMedica Health (RMH) nurse-led service delivery model leverages nurse administered limited obstetric scans, machine-learning quality improvement and tele-consultation for antenatal mental health. The combination of task-shifting, technology, mobility and education addresses challenges for expectant mothers face in accessing quality affordable antenatal care for diagnostic and mental health services. The nurse led model is being piloted in a peri-urban area of Mombasa, Kenya and we are working to expand the coverage to more densely populated urban areas in Mombasa and neighboring counties.  The World Bank estimates that there will be more than 40 megacities (10 million plus population) by 2030, the ability to scale and replicate this model across a multitude of cities could provide access to hundreds of thousands.

Healthy cities are a combination of urban planning for new construction or a reimagining the use of existing space and structures.  Our solution is based on tactical urbanism principles, low-cost, temporary changes to the built environment to improve local neighbourhoods and city gathering places.  The lever for reaching vulnerable populations is to leverage the strengthen of the built environment which can be structural as well as acting as an anchor of community activity, safety and trust. Location feasibility uses the same analysis principles as retail pop-up location planning.  Particularly for expectant mother’s location accessibility (first and last mile) and safety are paramount.

Only 9% of the Kenya population has access to adequate antenatal care services, for reasons such as financial hardship, travel hardship, lack of knowledge to services available and an acute lack of resources.  One study reported that the quality of maternal health care 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. 27% of the Kenya population lives in urban areas and continues to grow steadily.

RMH was designed for the working poor those who would typically access health services through public hospitals in peri-urbans.  Since opening our clinic our customer mix has grown to include middle and lower middle class families.  As we have opened our clinic, added educational services and deployed our RMH Locus services we have expanded geographically as well as in customer profile. While focused on expectant mothers, our sexual reproductive health education and antenatal counseling services has broadened our customer profile to include adolescents, faith based organizations, private schools and community based organizations.  

We receive continuous feedback from our weekly and bi-weekly sexual reproductive health classes for women and men, puberty and menstruation classes as well as peer counseling for university aged students.  It is through these education and peer counseling classes and interaction that we continue to refine our services model.  We conducted our initial focus group in May 2019 to critique our service model with 11 public hospital nursing departments and have interviewed public health officials and community health workers.  We schedule focus groups and interviews on a quarterly basis.     

Our antenatal care services of education, consultation, mental health, diagnostics and birthing serve the peri-urban vulnerable populations of Bamburi and surrounding areas of our clinic. Although we are for-profit we maintain close communication with public sector officials to determine health service capacity gap areas and in that manner we also serve the public health system. Akin to food deserts, urban centers have health deserts.

We use this information to map potential areas of service coverage expansion and then reach out to the relevant community based organizations, local businesses and faith-based organizations in those areas.  Based on their feedback we determine the need and viability of RMH Locus co-location pop-up agreements. We refer to this as a reverse referral. 

Our revenue sharing model with other health facilities and community groups which we co-locate with create economic activity and for the community.   

Our RMH Locus model, akin to pop-up retail models is intended address specific geographic service gaps.  Our nurses have been trained and certified to perform limited obstetric scans using the GE VScan Access, we are working with Whitekoat at the University of California Sacramento Medical School to being populating Synapse, the proprietary machine-learning platform to improve quality assurance of the scanning.  We are also in discussion with International Clinics of Kenya to design and integrate antenatal mental health tele-counseling services and ConnectforLife for an Interactive Voice Response system to support our antenatal care program and adherence.  Our sexual reproductive classes content utilizes publicly available material as well as material used with permission of the authors/institutions such as Columbia University Mailman School of Public Health.  

The approach we have taken is to integrate multiple aspects of innovation such as machine-learning, tele-consultation and mobile services with rigorous attention to operationalizing service delivery with a Value-Based Healthcare framework and financial sustainability.  Through a VBHC framework we aspire to improve health outcomes aligned to the premise of Universal Health Coverage, that receiving quality care does not adversely affect the financial stability of the patient or their family.  

To our knowledge, antenatal diagnostic services supported by machine-learning and antenatal mental health tele-consultation has not been attempted in Kenya urban and peri-urban areas.  The services portfolio takes existing technologies integrated into a service delivery model to serve new populations.   We also only take payment via MPESA to increase the transparency of payments while reducing the temptation for individual malfeasance.  With cashless payments our locationless services are safer for our workforce reducing the likelihood of robbery.

The primary technology we are building is a machine-learning platform for quality improvement of our nurse administered limited obstetric scans. Our business model factors in the cost of building a machine-learning antenatal scanning service as we pay a fee for each patient upload.  However, Whitekoat has been generous in flexible pricing to address financial sustainability and growth.  

From a clinic perspective our goal is to improve patient safety and quality assurance by using Synapse in a double-blind method where Synapse and the point-of-service task-shifting are compared independently and only when there is a discrepancy will further action (a second scan which we pay for with a second opinion) be taken.  Other technologies we will deploy are tele-consultation for antenatal mental health and an interactive voice system (IVR).   Tele-consultation will connect a patient with a counselor who will be available via laptop at the same location concurrently as the mobile limited antenatal scanning.  IVR system will be used for support antenatal care plan adherence and behaviour change.

Our reverse referral services model brings access to quality antenatal care services to vulnerable populations.  Although not limited to urban areas, the population density of urban communities allows us to reach a larger numbers within a similar geographic area.  We are able to immediately identify at risk  antenatal conditions and advise patients to seek the appropriate follow-up. Bringing services directly to vulnerable communities addresses service gaps within the health system without duplicating a service footprint.  This is done in consultation with the county department of health, and we are working on a dashboard that will anonymize aggregated data for the diagnostic services so that the public health officials are aware of our outputs and integrate them into their health indicators.  The limited obstetric scans, in the instances when we determine at risk pregnancies, should reduce the need for cesarean sections and reduce mortality.  Although the tracking of this data i.e. mother is beyond our points of access unless they are delivering at our facility.  Our hypothesis is drawn from participants attending our sexual reproductive health classes interaction, focus groups with nurses, midwives and community health workers.  Our delivery model targets SDG's 3,5 and 10 within the principles of VBH and UHC.   

2019: (we received our licensure in November 2018) - we are currently serving 300-400 persons a month. Due to the Christmas holiday any significant activity only began in March 2019. We anticipate by the end of 2018 a total of 3,000 will have interacted with our educational, ANC and diagnostic services.    

2023:   50,000 annually.  This will be driven by expanding the number of locations, scaling tele-counseling and tele-health services and entry into other countries such as Uganda.  

By the end of 2019 we intend to add a satellite location (with 10 kilometers of our current clinic).  Using a hub-and-spoke model, a network of satellite clinics will offer consultation, tele-consultation, essential medicines and basic labs.  Additional services such as limited obstetric scans, ultrasound services, more advanced blood work will leverage the capacities of our current clinic which is the model of a "hub".  We are in review with the Department of Health Kilifi and Mombasa counties to provide locationless services to support their health facilities.  The locationless approach allows us to determine the financial viability of adding locations tied to the community health impact that can be achieved.  In 18 months we intend to purchase land for a maternity hospital with an additional 2 satellite clinic locations.  In five years time we anticipate locations in Kenya and Uganda with 25 plus clinics.  

Currently our challenge has been the number of customers for our direct services.  Our education classes have been well received but direct services such as consultations, scanning and labs have been hindered by pricing and expectations of service levels.  They don't believe they can afford our services based the combination of services and medical devices at our facility.  Currently, we only accept payment via MPESA, this provides payment transparency and tracking as well as optimizing cash conversion for services which allows us to reduce the pricing of our services as we don't incur lengthy periods for accounts receivable.  However, as we move toward accepting NHIF (National Health Insurance Fund) we will encounter payment floats of three to six months.   

Currently we are completing our inspection and registration as a facility with the Kenya Medical and Dental Board which requires a separate licensure aside from our Nursing Council licensure.  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 systems 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. 

Customers for direct services: we contracted sales and marketing staff (health workers as well as sales persons) to outreach to facilities and communities to explain our services and pricing models.  We are also providing more community based opportunities inviting community leaders to our clinic.   

NHIF:  we intend to hire a NHIF dedicated account manager but we will maintain a revenue base does not exceed 30% of our total revenues. 

As mentioned, we are in the process of registering for inspection and licensure from the Kenya Medical and Dental Board which is required to become an NHIF approved facility.  

Personnel turnover: we continue to expand our hiring outreach and expand the pool of candidates we interview. We have also adjusted our probation hire period requirements and review standards.  

Corruption:  the issues we face with corruption is keep pushing the processes that are outlined and mandated and document all of our activities.  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. 

As of June 2019 - 4 FTE, 3 part-time contract workers (10-15 hours monthly) 

August 2019 - we will add 5 locum staff for our birthing center services, a part-time lab technician (currently 1 FTE lab tech) and 1-administrative assistant

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

Penina Mulwa: Nurse and Head of operations has 17 years of work across the Kenya public health, NGO projects and private sector experience (her own clinic and others).  Her experience as a public health worker and private clinic owner provides insight and guidance to our model's configuration and growth.

Michael Seo:  Managing Partner, has focused on health entrepreneurship in low-resource setting since 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.  

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. 

Whitekoat is a health start-up incubated by the University of California David Medical School.  Their mission is to strengthen health systems by improving how medical education is taught.  Through their learning platforms we have partnered with them to on a machine-learning platform for our obstetric scans.

International Clinics, a Kenyan health service provider has a network of over 400 Kenya health professionals which they use in their tele-health service.  We are partnering with them to build out tele-consultation collaboration for antenatal care.

RMH is part of the Transformational Business Network Health & Wellness 2019 Incubator cohort.  The incubator program has provided access to organizational resources and educated our senior staff of issues that affect how we operate and considerations for achieving growth.

Our customers are the working poor and expectant mothers who would typically seek services at a public health facility and private health providers. Beneficiaries are health providers public and private. Our business model provides value to vulnerable populations through affordable access quality antenatal care services services that go to them. We achieve affordability and quality outcomes through a VBHC framework focused on a nurse 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 revenue share model allowing private health providers the ability to expand their health services without additional capital costs or additional personnel.  Improving their financial performance as well as improving their services.  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.

Our revenue model is based on a fee-for-services model that currently only accepts MPESA (mobile money) payments.  We anticipate to be cash flow positive by October 2019, this does not include initial capital costs.  Our goal is to open 2 satellite clinics, one by the end of 2019 and a second within the first half of 2020.  The financial projections with two satellite clinics are anticipated to triple top-line revenue while doubling ongoing expenses, and improving free cash flow by 30%.  As mentioned previously we are cautiously moving toward accepting NHIF and other insurance payments which have higher reimbursement rates than we charge but must weigh the risk of long payment floats and not payments never recovered.

Grants are pursued specific to new programs or expansion support. Investment capital is being considered as we are concluding the Health & Wellness incubator program in July 2019 and have been in bi-lateral discussions with social impact investors.

The Solve partnership platform would help us access partners, expertise and resources (donor, governmental, technical and other solvers) that we currently do not have the ability or pathways to access. The east Africa health sector is predominately public sector, NGO and donor driven.  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.

The specific organizations we seek to establish relationships with are USAID, Gates Foundation, Hilton Foundation, MasterCard Foundation and other development agencies and foundations.  Health education and mental health counseling have a pronounced health impact but is a cost center for us.  We factor in the cost by cross-subsidizing these services with our antenatal services but the agencies and institutions often support programs and services that do not have a significant bottom line upside.  For RMH start-up costs are a significant challenge but we've seen our programs come closer to cost neutral since launching them. If we can lessen the burden of start-up costs (staffing, equipment and licenses) we would be able to accelerate our growth.