Measuring Patient and Business Outcomes at a Maternity Hospital in Kenya
Faith Muigai shares what she learned building the highest quality affordable maternity hospital in East Africa.
Faith Muigai is a Regional Director at the PharmAccess Foundation and the former Chief Medical Officer of Jacaranda Health, a social enterprise that designs and scales innovative and patient-centered care models for women and newborns in Kenya.
In this interview, she spoke about what she learned building the highest quality affordable maternity hospital in East Africa and the power of agile and low-cost solutions.
Could you start by sharing your journey in the health sector from Jacaranda Health to the PharmAccess Foundation?
My history in the health sector has included training as a nurse, managing research programs and hospitals, and now executive management.
I moved to the United States for college and lived there for 17 years. Then in 2012, I transitioned back to Kenya, where I joined Jacaranda Health, a social enterprise focused on innovation in scaling up maternal and child health and healthcare service delivery.
At Jacaranda, we opened two maternity hospitals in seven years and learned a lot of lessons. When we were getting started, we didn’t understand the market — particularly me, coming from the healthcare system in the United States. Over time, we came to understand the needs of the population in Kenya and how to run a sustainable business.
As a director and later Chief Medical Officer, I focused on the quality of care. I wanted to make sure the quality of care that I provided was similar to what I saw and experienced in the United States, having had children there myself.
I wanted an independent party to assess what I was doing and tell me if I aligned with international standards. We know that in lower-middle income countries, most hospitals don’t meet quality standards and they don’t know how to improve.
In 2017, I enrolled in a program called SafeCare that assesses facilities and shares a roadmap to reach international standards of quality and safety. I was able to attain the highest level of certification that the program provides.
After Jacaranda, I became Regional Director for the SafeCare program at the PharmAccess Foundation. So you can see a natural progression from managing a hospital and implementing these quality standards to now running the program that certifies hospitals for quality health service delivery in Africa.
Let’s talk about Jacaranda Health. As you said, it is widely recognized as the highest quality affordable maternity hospital in Kenya. Could you explain what you were doing differently compared to other hospitals?
As an organization, we focused on making sure we had systems and processes that worked. We instituted quality standards that were applicable to our local context. And we always evaluated ourselves from a clinical standpoint, as well as a business standpoint.
Many people in this environment don’t look at healthcare as a business. And that’s where they fail. They don’t ask themselves, “What do I have to put in place to achieve my desired outcomes?”
One important variable is staffing — this is huge. When obstetrics goes bad, it goes very bad, very quickly. If I don’t have skilled professionals who are equipped to handle these emergencies, the outcome will be poor. Women will talk about their poor experience in their communities, and then you don’t get more patients through referrals. It has a trickle down effect to your bottom line.
You need more women delivering in your facility and more women talking about your facility. For me, the golden standard to achieve those outcomes was quality of care.
Now, when you look at the consumer industry, you have different organizations validating the quality and effectiveness: Is this a good drug? Does it achieve the desired outcome? Is the generic drug as effective as the brand name?
The same rules apply to healthcare service delivery. Are you providing efficient services? Are you providing value for money? Are you providing care that is patient centric, because patient satisfaction is important to you and because it brings more business to your facility so that you can generate revenue?
How were you able to keep these services affordable to women, while still making sure the hospitals were financially sustainable and high quality?
We were very concerned about our pricing in the beginning. We were trying to do good. As we grew, we realized that it wasn’t about “doing good.” It was about value for money.
There is the concept of “willingness to pay” vs. “ability to pay”: Are customers willing to pay for the goods or services you are providing?
I found that, even in informal markets, “willingness to pay” was the most important factor.
If people understood the value of the services that were being provided, they would figure out a way to pay for them.
We realized that going cheap was not the best route. Instead, we focused on pricing so that we could make ends meet.
We were still conservative — we were one-tenth of the cost of some higher level facilities — but we spent a lot of time developing our business model to ensure our prices made sense.
We did exercises: If a woman is admitted from point A to B, what does it cost for us to provide these services? We knew the costs of all our services — the supplies, the human resources, the administrative fees, the direct and indirect costs.
Then we built a margin that was reasonable and not excessive or exorbitant. That way, we were still an affordable choice, but our services could align with higher level facilities and we could invest in our people and infrastructure.
My job was to ensure that women accessed antenatal care, which is vital for a healthy pregnancy and delivery. But to make money, that antenatal care needed to translate into skilled delivery in our facility. We also built an operating theater for cesarean sections and emergencies, but the space was expensive. So we opened it up to other types of surgeries, such as elective gynecological cases that could bring in money to help sustain the business.
In that way, we expanded our scope of services from what we had originally intended, but it made sense from both a business and clinical standpoint.
You mentioned that understanding your costs and pricing your services were important elements of Jacaranda’s success. Some people might be surprised to think about a hospital this way, especially one that serves lower income patients.
A lot of practitioners come in with a social mission to do good. But they have not strategically mapped out how they can become a thriving business. That was something Jacaranda did very consciously. No one likes to say “profit” in healthcare, but you need profits to invest back in your business.
I believe that is what made Jacaranda successful. We were always looking at metrics, and not only clinical metrics, but also business indicators. That includes human resources indicators like employee retention, as well as patient wait times, because dissatisfaction can result in lost customers.
Did any parts of Jacaranda’s business model change?
Everything evolved. We shut the first hospital down. The surrounding population was elderly, so they were not having babies. It was also difficult to safely access our facility in the middle of the night when emergencies happened.
We learned from those mistakes when we built the second hospital. It was on a busy road, so access and security were not a problem. The income levels varied from lower to middle income, so we had a variety of clients with and without insurance. Patients had access to mobile money. There were also more women and men of reproductive age.
In the first hospital, we had averaged about 20 to 30 deliveries a month. Within two years of moving to this new facility, we reached 100 deliveries a month and patient numbers were soaring.
Could you explain what you mean by “patient centric” care? What are some examples from your work at Jacaranda Health?
Our leadership understood that you have to learn fast and fail fast. You also have to learn about the population you’re serving and design your services to meet their needs, not your own.
I’ll share an example. In the beginning, we thought we could run a maternal facility that focused on deliveries and then refer mothers to a pediatrician for the baby’s care. That’s what happens in the United States, right? After I had my baby, I was scheduled an appointment to see a pediatrician in one week. But in a community health setting, there is no time to see a pediatrician. Everything has to happen at the maternity facility.
So we had to change the design of our program from a Western approach to an African approach, where the practitioner attends to the mother and the newborn in the same appointment. Mothers are only referred to a pediatrician for emergencies. As a result, we needed to upgrade the midwives’ skill set so they would be confident in newborn care.
We also learned that, although many mothers could not afford another child, they wouldn’t show up for an appointment to discuss family planning. But they would attend an appointment for the baby. So we redesigned our follow-up family planning appointment, as well.
We were customer centric and redesigned our programs to fit our patients’ needs, but we stayed true to our intentions for founding the hospital.
Are there any other companies that are doing a great job to improve the quality and access of healthcare in Kenya?
There are so many enterprises and solutions that are happening. The thing is, we haven’t mapped them out.
That’s the problem with our system in Kenya; there are so many innovative solutions, but people are working in silos, and we don’t have a repository of who is doing what and where. If we all came together, do you know how many people we could reach? But we don’t because we see each other as competitors.
What advice would you share with students who want to enter a career in health?
My first piece of advice is to learn fast, fail fast. That phrase has always resonated with me because we often dwell on the problems, but we don’t catalyze solutions quickly enough.
Second, public health professionals need to listen to the local market, understand the local need, and embrace local solutions. Don’t assume that because you come from Stanford or Harvard, you know everything.
Let me ask you a question — have you been to a hospital lately? How did you call your nurse? You press a button like you’re on an airplane, right?
That doesn’t work in Kenya. So when you’re looking at solutions, focus on realistic and low-cost solutions. You know what I did at Jacaranda? I bought bells and kept them on the patients’ side tables.
These low-cost solutions also apply to business decisions. Let’s say you don’t have sophisticated computers or software, but you need a dashboard. You need to see information related to your business — where you’re in the red, where you’re in the green. Guess what? Excel spreadsheets will do that for you.
I went to a conference that was all about artificial intelligence and blockchain. I told them, don’t talk to me about artificial intelligence and blockchain when I’m still trying to figure out how a patient can reach the nurse at the nurse’s station! So, how can you innovate, but also be agile?
Third, help change mindsets and cultures. Don’t come in with a solution — come in trying to brainstorm the solution. Design solutions that work within this environment.
Finally, understand the language and the business of health, and how to translate it in a way that is digestible to the local environment. And then partner with organizations that will help you can showcase what works, because you can then take it up on a policy level.
