In a move anticipated to transform healthcare in Kisumu County, H.E Governor (Prof) Anyang Nyong’o recently rolled out the second phase of the innovative MARWA Kisumu Solidarity Health Cover, a Universal Healthcare Coverage (UHC) prototype ecosystem. This initiative aims to expand access to UHC through social health insurance, particularly targeting uncovered populations such as the indigent and those in the informal sector. Recruitment of self-joining households from the informal sector has started and the plan is to have everyone in the county enlisted.
“Marwa”, a Luo word for ‘ours’, is a digitally enabled health insurance scheme under the umbrella of UHC. It is designed to ensure that indigents and those in the informal sector, such as those in the villages and those working in jua kali sectors, are accorded access to affordable and quality healthcare services, whenever they need it, and without suffering financial hardship.
Kisumu County implemented the initial stage of the Marwa Scheme massive registration drive in 2018 under the national UHC pilot programme. Utilizing a public-private approach, the county partnered with PharmAccess for technical assistance. The partnership facilitated digital registrations of eligible households into the National Hospital Insurance Fund (NHIF) and co-funding of health insurance premiums, deployment of the SafeCare digital assessment tool to enhance the quality of healthcare and, generation of digital dashboards to increase transparency, create efficiency and share data to improve decision making. The 49 healthcare facilities in the scheme and, Community Health Promoters (CHPs) were trained to digitize and capture data electronically thus helping them to plan better for preventive healthcare.
Prof Nyong’o says that, “going forward, Marwa will allow individuals in the informal sector who are unable to afford the proposed health insurance premium to pay half while the county covers the rest.”
Since the introduction of Marwa in 2018, insurance penetration in Kisumu County has grown from 12percent to 22percent. The latest initiative is aimed at bolstering health insurance penetration to 70-75percent by 2027.
Marwa works as both an enabler and aggregator by mobilizing funds for health, promoting equal access to quality health care for the poor, pooling health risks and preventing the vulnerable from impoverishment. As an enabler it improves the efficiency and quality of health care.
Beneficiaries can access both inpatient and outpatient care under the NHIF Supa Cover benefits package at 49 selected public health facilities that are evenly spread across the seven sub-counties.
“Since it started operating, Marwa has facilitated the harvest of data hence data-driven decisions are being undertaken in Kisumu County.” Says Governor Nyong’o.
PharmAccess Kenya, Country Director, Dr Wasunna Owino, says that through adoption of digitalization and technological innovations such as M-TIBA, quality, affordable and accessible healthcare can be achieved for all as envisioned in article 47 of the Kenyan constitution.
He notes that, the health system in Kenya as well as Kisumu County are characterized by a downward spiral of poor supply and demand that lead to inequities. Banks are unwilling to invest in clinics and the clinics cannot improve the quality of their care. Poor quality of care, in turn, drives patients away from seeking care. In all, people lack trust in the health system. Digital innovations present a pivotal opportunity to address such healthcare challenges to leapfrog change in health ecosystems.
According to Dr Owino, PharmAccess as an organization believes that connectivity and the free flow of personal data in health can equally spark exponentially, leading to yet unknown health care solutions with unprecedented gains for patients, their health care providers, and their health ecosystems. We cannot continue to do the same but must innovate! It is for this reason that, PharmAccess is instigating a wildfire of initiatives on connectivity in Kisumu County to transform the health systems towards inclusive UHC.
Dr Wasunna further explained that PharmAccess worked with Kisumu County and the National Hospital Insurance Fund (NHIF) to identify the poorest households that were eligible for financial protection support (NHIF Super Cover) based on means testing.
PharmAccess support to the MARWA ecosystem encompasses other health systems reforms which include quality care improvements by leveraging mobile and digital technology. Through the SafeCare stepwise methodology, participating facilities are initially assessed and, thereafter, a quality improvement plan is provided to address gaps, with clear roles and responsibilities provided.
According to Dr Wasunna, low quality health care is increasing the burden of illness and heath costs globally including Kenya, it can result in a lack of trust from patients therefore affecting empanelment of clinics in insurance schemes.
“The aim of incorporating the quality-of-care aspect into the MARWA ecosystem is to enable institutions to have a medically and financially healthy organization, which translates into patient and staff safety, increased returns on health investments and, better health outcomes. Through the safe care methodology healthcare facilities are guided on where and what to improve, to provide quality health services,” Dr Wasunna added.
As part of the Marwa ecosystem, a ‘care bundle’ model that uses mobile data to prioritize care for vulnerable patient groups such as pregnant mothers throughout the pregnancy journey was introduced to support behavioral change in pregnancy care. The number of pregnant women completing at least 4 scheduled antenatal clinic visits (ANC), improved from 58.7percent to 63.3percent while health facility deliveries increased from 69.5percent to 94percent. Health data has been used by the county to identify disease outbreaks and hotspots in real time, allowing for targeted epidemic preparedness and response.
But Kenya continues to face challenges when it comes to health care and related services such as health insurance. Through the existing national health insurer, only 25 percent of all Kenyan population are covered under NHIF. Enrolling informal sector members who can pay for insurance is difficult and indigents who can’t pay have been elusive to the 60-year-old NHIF, it has also been more challenging to collect premiums from informal sector workers.
In 2018, as part of the UHC journey, four counties were chosen for a pilot study, with the larger plan being a rollout to the other 45 counties. Kisumu County, one of the pilot counties, adopted the Marwa scheme to serve both demand and supply needs for improved quality of care.
According to the Kisumu County Executive Committee Member (CEC) for Health Dr Gregory Ganda, the County digitized its platform to accelerate coverage using an interoperable platform which acts both as an enabler and aggregator of funds.
Dr Ganda adds that data collected through Marwa is used to improve care delivery for the indigent and most vulnerable members of the community and also to sustain facilities by ring-fencing health funds. In other words, the funds are ploughed back to improve services instead of going to the county revenue fund where they can be diverted to non-health expenditures.
“Marwa’s footprints are those of a robust and resilient primary health care system, as level one and two facilities have realized capitations and resources ploughed back directly to them to facilitate their development, community health promoters (CHPs) are helping us to cover the right persons and identify indigents to be supported and M-TIBA in supporting the identification and digitization.”
He says that setting up and operationalization of the Marwa has generated great lessons for the National roll-out of the Universal Health Cover (UHC).
“The national government UHC plan, has similarities with the Marwa ecosystem and can therefore help other counties to look at their situations and come up with their customized local packages.”
PharmAccess and its partners have contributed to the health sector in Kisumu County and generated many lessons for other counties.