MNCH in the Kenyan context
In Kenya in 2019 1.5 million babies were born [37]. Of women who are pregnant, 96% attended at least one antenatal care visit, and 58% attended antenatal care at least four times while 62% attended a skilled delivery [38]. The maternal mortality rate (MMR) is 342 per 100,000 live births and the neonatal mortality rate (NMR) is 21 per 1,000 live births [4]. Healthcare services are provided by six levels of facilities, ranging from community services (level 1) to national referral hospitals and large private teaching hospitals (level 6). Antenatal and postnatal care services, including immunizations, are provided by most level 2-6 facilities such as dispensaries, maternity clinics and hospitals. Delivery services, including caesarean sections, are mainly provided by maternity health centres (level 3), (sub)county referral hospitals and medium and large-sized private hospitals (levels 4 and 5) [39].
Program Setting
MomCare includes a predefined care pathway for MNCH with predetermined costs and quality standards. First, an ecosystem was created by redefining the care pathway based on internationally agreed standards for MNCH [40] and a network of clinics was put in place. Secondly, PAF enrolled pregnant women in a subsidized health insurance scheme by offering a ‘health wallet’ on their mobile phones, which was used to pay for care provided by clinics within the network. The ‘health wallet’ runs on a digital exchange platform, called M-TIBA (mobile treatment), and has been developed by Carepay and PharmAccess [41].
MomCare was first introduced in an urban area of Nairobi County in November 2017 and expanded to the rural area of West Kenya from May 2019 onwards. MomCare started in Nairobi with three clinics and ultimately expanded to 18 clinics in 2019. Participating clinics vary from level 2 to 4. Providers were selected and contracted by PharmAccess, connected to the digital platform and received support through SafeCare, a care quality improvement methodology [42]. In the time-period of this study (2017-2020), these 18 clinics supported 8,821 women during pregnancy within the program, resulting in 5,085 newborns delivered within the network.
Vbhc Development Approach
Since no implementation models existed yet for low-resource settings, the VBHC approach needed to be developed from beginning to end. In the program, multiple activities were implemented sequentially or simultaneously over time. This section describes the three stages of this process: (i) Theory of Change (ToC) development, (ii) VBHC adaptation, and (iii) iterative feedback cycles. We report on our methods following the checklist for reporting ToC (see Additional file 1).
In the first stage, a ToC approach was used to design the program, and monitor and evaluate the implementation process [43, 44]. The ToC describes how MomCare brings about long-term outcomes through a logical sequence of intermediate outcomes [45]. An advantage of this approach is that it allows to create regular feedback cycles to continuously learn and improve during the implementation [46]. The ToC was developed through several iterative rounds in consultation with stakeholders on different levels [45]. Interviews and focus group discussions with the involved stakeholders were held to explore the context, challenges, problems, and solutions in providing high quality maternal care. Combined with an extensive document analysis and literature review the ToC was designed, as shown in Figure 1.
Using a backward mapping approach [47], we first defined the long-term goals as the desired impact of the interventions (right-hand box in Figure 1). The three long-term goals of MomCare are: (1) healthy mothers and babies, (2) sustainable business for providers, and (3) transparency of outcomes and costs throughout the care journey. Second, we identified the changes needed to achieve these goals by specifying causal pathways with specific intermediate outputs and outcomes (boxes three and four). The causal pathways are initiated by the six interdependent components of VBHC shown in the second box of Figure 1.
Table 1
How each component of the VBHC framework was translated into context-specific activities.
1
|
Organize into integrated practice unit (IPU)
|
2
|
Measure outcomes and costs for every patient
|
3
|
Move to bundled payments for care cycles
|
4
|
Integrate care delivery across separate facilities
|
5
|
Expand excellent services across geography
|
6
|
Create IT platform
|
a
|
Redefining of care pathways
|
a
|
Collecting patient reported (PROM) and clinician reported outcomes (CROM)
|
a
|
Implementation of bundled payments
|
a
|
Introducing hub and spoke model
|
a
|
Use a cohort-based approach (cohorts 1-7)
|
a
|
Implementation of digital payment platform (enabling data collection of CROM)
|
b
|
Implementation of quality workshops and quality certification (SafeCare)
|
b
|
Implementation of outcome measurements by digital tools and use of billing data
|
b
|
Offering comprehensive coverage MNCH
|
b
|
Implementation of referral system (content package across different facilities)
|
b
|
Start of program in urban area (Nairobi) and expansion to rural areas (Kakamega and Kisumu)
|
b
|
Implementation of patient journey tracker app (enabling data collection of PROM)
|
c
|
Investments in medical equipment and quality improvements
|
c
|
Implementation of journey score
|
c
|
Implementation of outcome-based bonus payments
|
|
|
|
|
c
|
Implementation provider of performance dashboard
|
|
|
|
|
d
|
Implementation of contracting and monitoring process between PAF and clinics
|
|
|
|
|
|
|
The activities address three major issues described in the first box of the model: women have a high risk of bad pregnancy-related outcomes, care providers do not always provide quality care and the health system lacks in transparency and equity. The ToC also reflects that the progress of the program is influenced by factors in the external environment not directly related to the interventions, such as government investments in expanding Universal Health Coverage (UHC) or an external shock like the COVID-19 pandemic.
In the second stage, the six components of the VBHC framework were adapted to the MNCH context in Kenya as listed in Table 1. Adaptation of the VBHC framework is necessary as health systems differ and effects of health system interventions depend on cultural, financial and social fit. We elaborate on the adaptation of outcome measurements, bundled payments and the digital platform as these components were seen as most impactful to patients and providers.
Outcome measurements
Defining outcomes that reflect the total cycle of care is key within any VBHC initiative. Outcomes should be disease (or in some cases subpopulation-) specific and multidimensional [29]. However, designing a valid and reliable outcome set can be complex and time-consuming, especially regarding standardization, which is required to compare between providers and health systems around the world [48]. MomCare used an adapted version of the standard set Pregnancy and Childbirth as developed by the International Consortium for Health Outcome Measurements (ICHOM) [49]. The ICHOM outcome set includes both clinician reported and patient reported outcomes such as maternal morbidity and birth experience. However, as countries differ in health systems, culture and language, exploring the applicability of outcome sets is required [50]. In a previous study in a comparable group of mothers [51], the applicability of the ICHOM set was explored by a two-round feasibility assessment in which pre-selected outcomes were reviewed and finalized by local Kenyan providers and medical experts. In total 14 outcomes were selected as being appropriate in the Kenyan context of which five are patient-reported. The program used these selected outcomes, which were incrementally implemented along the unfolding of each of the cohorts and perfected over different learning cycles.
Bundled payments
As shown in Figure 1 Activity 3, the program implemented bundled payments. A bundled payment can be defined as a one-off or periodic lump-sum payment for a range of services delivered by one or more providers based on best practices or by following clinical pathways with an increasing emphasis on outcomes [52]. A bundled payment suggests that financial risks of care delivery are shifted from payer to provider. As a result, providers are incentivized to coordinate care across settings, deliver appropriate care and reduce costs over the full care cycle [53]. As Kenyan providers are inexperienced using other payment models than fee-for-service and capitation, the program chose an iterative approach by implementing sub-bundles that resemble each phase of the care pathway instead of one bundle that covers the whole pregnancy episode. In total 130 activities, that were separately billed before, were grouped into 32 sub-bundles. The bundled payment model also included a pay-for-performance scheme that is derived from a patient journey score. The patient journey score is a standardized risk adjusted metric that resembles the adherence to the maternity pathway and the care delivered in accordance with the guidelines [10]. The score ranges from a minimum of 0 (no care received) to a maximum of 5 (well attended and managed journey). In order to maintain provider involvement and maximize effects, bonus payments were made available based on the patient journey score and providers received feedback on their performance.
Digital platform (M-TIBA)
The digital exchange platform connects patients, providers and payers by directly channelling ring-fenced healthcare funds into mobile ‘health wallets’. Each time the wallet is used at a healthcare facility, medical and financial data is collected. This data provides critical insights into the costs, utilization and quality of care, enabling more effective allocation of resources. At enrolment, pregnant women were asked questions through a digital enrolment app on socio-economic status, demographics and obstetric history including pre-existing medical conditions. Healthcare providers submit their (invoice) data following the International Statistical Classification of Diseases and Health Related Problems, ICD-10 [54]. The digital exchange platform enriched the collected data, applying business rules to calculate the patient journey score and concomitant quality bonus for each clinic. Enrolled women received a text message at three moments during the patient journey to capture PROMs and in addition received an ‘end-of-journey-call’. As use of mobile phones is widespread in Kenya, text messages via SMS services are an efficient and reliable way to capture patient reported outcomes [55, 56].
Feedback loop
In the third stage, a feedback loop was created between outcomes, outputs and activities to implement improvements every time a new group of mothers (a cohort) was onboarded in the program. Learnings from earlier cohorts were used to adjust activities to improve outputs and outcomes for later cohorts. A total of seven cohorts, enrolled in the period from 2017 to 2020, were included in this study. An overview of program roll-out and the learnings from the iterative feedback cycles are described in the Results section.