Inside Kenya’s Value-Based Care Pilot Tackling Maternal And Neonatal Mortality

Maternal and neonatal health (MNH) remains a key challenge in Kenya. Kenya’s maternal mortality ratio is 355 deaths per 100,000 live births, and its neonatal mortality rate (NMR) is 21 deaths per 1,000 live births. These rates are a far shot from the 2030 Sustainable Development Goals (SDGs) targets of 70 deaths per 100,000 live births and 12 deaths per 1,000 live births, respectively.

Despite decades of investment, advisory and training, maternal and neonatal mortality rates in many low and middle-income countries (LMICs), including Kenya, remain high. The primary focus has been to increase the volume of available and consumed healthcare, such as building more healthcare facilities, training and hiring more nurses and doctors, prescribing and funding more medicine. Contributions by programmes such as the national government subsidised Linda Mama MNH have been notable. For instance, access to skilled birth attendance improved from 66% to about 89% between 2014 and 2022.

The quality of maternal and neonatal healthcare is the main driver of successful healthcare delivery and improved health outcomes, with over 80% of maternal deaths being attributed to poor quality of care. This underscores the need for new approaches to MNH, such as value-based care (VBC) programmes. Can alternative health financing approaches improve Kenya’s maternal and neonatal health outcomes?

The value-based care pilot programme

A value-based care programme is a healthcare approach that focuses on delivering high-quality care at a lower cost by prioritising outcomes that matter most to patients. The goal of a value-based care programme is to shift the healthcare system from a fee-for-service model, which incentivises providers to perform more procedures and services, to an approach that rewards them for achieving better health outcomes for patients.

FSD Kenya has partnered with Britam to design and pilot a value-based care approach to maternal and neonatal care for Britam’s Afya Tele microinsurance clients. A previous study had attributed the high MNH claims under Britam’s Afya Telehealth insurance product, which is targeted at small business employees, to mothers not attending the recommended minimum four antenatal care (ANC) visits per pregnancy. This inadequate access to care presumedly led to complications during and after delivery for both mothers and babies, resulting in longer hospital stays and re-admissions, and thus affecting the product’s commercial viability.

A first step in this partnership was a User journey study to understand the pain points and how access to quality care could be improved.  The insights from this research informed the design of the maternal and neonatal value-based care pilot programme. The study targeted mothers covered under the Afya Tele product who had delivered in the previous two years. Contrary to expectations, the study showed that all the mothers interviewed during the study had attended the recommended four ANC visits.

However, the value of care varied considerably in breadth, quality, and timeliness. Non-clinical aspects of the care, such as how the mothers were treated, were also reported as crucial. Treating expectant mothers with respect has been shown to impact MNH outcomes in other programmes. The inability to access the right quality and kind of care timely manner had a knock-on impact on the health outcomes, leading to extended hospital stays for mothers and neonates and re-admissions.

Informed by these insights, the value-based care programme design entailed defining the right package of MNH care to cater to most of the needs presented during the pregnancy journey, and pricing it at a level that is attractive to the healthcare providers. The design also built in incentives for both mothers and the healthcare facilities to seek care and deliver the package of care, and clear metrics to monitor the quality of care. The pilot leveraged Jacaranda Health’s PROMPTs, a suite of digital tools that support mothers to seek healthcare and amplify their voices through a feedback mechanism to improve the quality. Besides the behavioural nudges and feedback mechanism, PROMPTs also provides advice to mothers on MNH. The VBC programme, dubbed Lea Mama, was launched in May 2024.

The pilot has realised better MNH outcomes compared to the national figures, such as 38% caesarean sections and 62% spontaneous normal delivery, compared to 53% and 45% respectively as per the Kenya Health Information System (KHIS), and 40% and 60% for the overall health portfolio. Compared to the overall Afya Tele pre-pilot portfolio, the miscarriage rate dropped by 50% and post-delivery admissions reduced by 73%. Generally, the mothers were happy with the care received under the programme. They reported being treated with respect during ANC visits (100%) and delivery (99%), with a net promoter score of 9.4.

What next?

While the outreach is still too low to provide a critical mass for business viability analysis, there are indications that the approach could help manage the cost of MNH care. That said, the pilot provided a good understanding of the cost of MNH, which will inform future health financing contracts.

Despite positive progress during the pilot phase and the prospects for greater scale, two interrelated challenges threaten the programme’s long-term viability and impact, and need to be resolved. The issues, which relate to healthcare facilities’ engagement and collaboration, are: a) absence of structured incentives for providers to adopt preventive care and value-driven practices, which lead to fragmented care pathways; and b) a limited understanding of health outcomes due to data unavailability stemming from the additional reporting burden on the clinicians and administrators.

The next phase will focus on incentivising quality care delivery and streamlining health outcomes data reporting. The main objective is to collaboratively develop a scalable, outcome-based provider model that has the full buy-in of healthcare facilities.  In addition, the behavioural nudges and advice through PROMPTs will be availed to an additional 3,000 mothers.

The value-based care approach shows promise regarding alternative ways of healthcare purchasing. If the model is proven, it would be rolled out to the rest of Afya Tele clients (approximately 20,000) beyond the current pilot area, and subsequently extended to similar products within Britam, such as Kinga Ya Mkulima, which currently has about 178,000 policies. Moreover, the project team is part of the new Kenyan value-based care community of practice, where the principles, insights, and learning are continually being shared.

Read Also: Britam, FSD Africa, and Jacaranda Health Launch Partnership to Improve Maternal And Neonatal Healthcare In Kenya