A PROVIDER-DRIVEN HEALTH PLAN IN KENYA

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1 Bima Poa A PROVIDER-DRIVEN HEALTH PLAN IN KENYA

2 Introducing Bima Poa Bima Poa, which means cool insurance in Swahili, is a provider-driven health plan in Western Kenya. It combines health insurance for low-income groups with affordable loans for the clinics involved as well as a quality improvement program. The Bima Poa health plan is a partnership between the Kenyan NGO Kisumu Medical and Education Trust (KMET), insurance company AAR, third party administrator Africa Medilink, Kenyan mobile network operator Safaricom and Dutch NGO PharmAccess. The program started in September 2013 on a small scale with six providers from KMET s social franchise healthcare provider network Huduma Poa, and is expected to expand with the addition of twelve providers per year. Healthcare providers tend to have a unique position within their communities. Not only do they perform the role of caregiver and confidant to their patients, they also often hold important social positions. The Bima Poa health plan leverages their unique position and has entrusted Huduma Poa providers with an active role in marketing, sales, administration, outreach and education. Bima Poa takes an innovative approach to strengthening the local health system as a whole: it not only supports health insurance for low-income groups, but stimulates quality improvement and access to capital for the participating healthcare providers. Premium collection and renewal services take place exclusively through the M-Pesa mobile payment system. In future, more mobile health (mhealth) solutions may be introduced.

3 4 BIMA POA Kenya s health financing landscape The last three years have marked an exciting time for the healthcare sector in Kenya. This period has seen investments and successes in all parts of Kenya s health sector, from health provision and insurance to pharmaceutical production. At the same time, around 33 million Kenyans lack any form of basic insurance, and are treated in ill-equipped and poorly staffed facilities. Kenya s health sector faces enormous deficiencies in coverage and infrastructure. Open Capital Advisors The Next 33,000,000. How the private sector is reforming health care for Kenya s mass market, October 2012 Kenya currently lacks a comprehensive health financing strategy and the discussion on universal health coverage is ongoing. In the early stages of Kenya s evolution towards universal health coverage, private micro health insurance schemes supplement government initiatives. As such, private prepaid schemes and ensuing increased risk pooling can play a significant role. In addition, they can provide households with financial protection from impoverishment due to catastrophic health expenditure. To serve the Kenyan mass market, private health care players need innovative business models that can supply consistent quality and coverage with higher volumes and lower prices. Providers see that mass-market insurance will significantly increase demand for outpatient and preventative care. Research suggests that the traditional insurance model is too expensive to reach mass-market customers. Through Bima Poa s provider-driven approach, we are trying to address the challenges in Kenya s heathcare sector and move towards universal health coverage.

4 6 BIMA POA Developing Bima Poa The Bima Poa health plan offers a fully developed benefits package of basic healthcare services, focusing mostly on maternal care and primary care such as consultations, lab services and medicine. Bima Poa covers the most common healthcare events and was designed to be affordable for currently underserved markets. As such, Bima Poa contributes to improving the quality and predictability of the healthcare provided, but also creates the potential for cost savings that can be passed on to the end consumers. Package design Both the healthcare providers and community members were involved in the package design. Market research through exercises such as CHAT sessions (Choosing Healthplans All Together) among low-income consumers showed a strong preference for coverage of primary care. Actuarial analysis was used to calculate the premium and the average expected medical payout and financial risks for stakeholders. Household surveys revealed that a package that costs KES 8,000 per year per household (approximately USD 92) is deemed affordable for the target population. Also, healthcare providers were trained to develop their own business case for the health plan. Healthcare providers were trained in health education, sales, enrollment, administration and claims. A unique aspect of the Bima Poa health plan is that providers carry part of the risk through capitation. Now that Bima Poa has been rolled out with six providers in Siaya and Kisumu, it is undergoing continuous monitoring and evaluation adjustments.

5 8 BIMA POA How it works As a provider-driven health plan, Bima Poa depends on the entrepreneurial efforts of the healthcare providers and their relationships with the community. Healthcare providers in the Huduma Poa network and community leaders are actively involved in raising awareness about health care in general and about the Bima Poa health plan in particular. This greatly increases the likelihood of enrollment, and reduces operational costs for the health plan as a whole, as the healthcare provider is incentivized by the ensuing business benefits. Healthy risk pool As providers receive a set amount for each enrolled person (capita- tion fee), they have an incentive to enroll as many community members as possible in order to create a healthy risk pool for the program. By enrolling both the young and the old, the sick and the healthy, healthcare providers are able to create a sustainable pool of financing. In this light, it is imperative that they make an active effort to enroll wide segments of their communities rather than just those patients already visiting their facilities. In addition, Bima Poa employs a blend of marketing tools, such as health fairs, health plan launch events, games, mobile communications and community mobilization. Tried and tested monitoring and evaluation tools assess the effectiveness of these efforts. Quality of care The quality of care and service delivered is vital to Bima Poa s success, as people will only be willing to pay upfront if they are confident they will actually receive proper healthcare service if and when they need it. For this reason, all providers in the Huduma Poa network must be enrolled in the internationally accredited SafeCare quality monitoring and upgrading program. As clinics are obliged to meet at least minimal requirements and to participate in the step-wise quality improvement programs, the quality improvement process becomes transparent. Access to capital Clinics in the private healthcare sector in sub-saharan Africa service 50% of the population, yet have a hard time securing loans. The healthcare providers in the Bima Poa health plan are given the chance to finance quality improvement of their facilities by applying for a loan via the Medical Credit Fund. The Medical Credit Fund and its technical partners provide business and quality trainings, and help clinics to draw up a quality improvement plan for the SafeCare program as well as a business plan. The steady and growing income stream generated through the health plan should suffice to repay the loans and allow for further investment in the facility. The enrollment process Community health workers approach potential clients door to door or through marketing forums and outreach activities. Once a client has expressed their wish to enroll, the family selects a preferred provider. Then, the client uses M-Pesa to make an immediate payment into AAR s M-Pesa account. The community health worker drops off the activated forms at the healthcare provider. KMET then enters client activation data into a centralized Bima Poa system. Enrollees receive an insurance card which contains their biometrics and photograph. The third party administrator African Medilink uses the Bima Poa system to process enrollment information, claims and utilization data. It also ensures that administrative processes meet predefined standards, connect up correctly and provide accurate and reliable data for operations and management purposes.

6 10 BIMA POA The way forward Bima Poa aims to provide access to quality healthcare services for low-income earners in Kenya. If the pilot proves successful, the program is expected to be scaled up. Partners within Bima Poa The health plan is based on a partnership between parties with unique roles within the healthcare supply chain. Each partner contributes a specific expertise. The program started in September 2013 with six providers in Siaya and Kisumu, with a projected enrollment of 5,000 people by the end of the year. Eventually, all 52 providers within the Huduma Poa network could be included, which would entail a potential customer base of over 410,000 people. Learning incubator In the early stages of Kenya s evolution towards universal health coverage, private micro health insurance schemes may supplement government initiatives. This provider-driven health plan can be seen as a learning incubator, possibly providing valuable lessons for both the private and the public sector on how to reach excluded groups. mhealth PharmAccess and Safaricom are currently exploring opportunities for mobile health applications within Bima Poa. This may include making use of SMS or smart phone services and online social networks. Key considerations for applying any new mobile technology to the health plan are whether it can provide significant value to the healthcare providers or the customers, whether it adds channels that are currently unavailable and whether it improves the efficiency and effectiveness of Bima Poa operations. KMET, a Kenyan non-governmental organization with a social franchise provider network, coordinates sensitization, (mass) marketing campaigns, sales, enrollment and premium collection. Huduma Poa is one of KMET s networks of healthcare providers which deliver care and promote the Bima Poa health plan among community leaders and members. Africa Medilink, a dedicated micro-insurance third-party administrator, manages the administrative processes of member registration and payments, and provider claims and reimbursements. AAR is the largest private healthcare company in East Africa. It ensures that regulatory requirements are met, transfers the risks of medical costs and pays claims. Safaricom offers infrastructure for mobile payment solutions and future mobile health initiatives. PharmAccess Foundation acts as a facilitator for implementation, organization and monitoring of the partnership and its progress towards establishing and executing the health plan.

7 The PharmAccess Group stimulates access to quality health care for low-income people in sub-saharan Africa through complementary initiatives on both demand and supply sides. Our work combines health insurance schemes, standards for quality improvement and loans for medical clinics. The Amsterdam Institute for Global Health and Development conducts in-depth operational research and impact assessments of our interventions. The organizations within the PharmAccess Group share a common goal: achieving inclusive health care for the people of Africa. Follow us on