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One Family Health Rwanda: Achievements and Challenges 2012

IPIHD1 Case Study #101

Liz Charles, Jeffrey Moe, Richard Bartlett

NOTE: Students reading the case for lecture by Jeffrey Moe, Nov 14, 2013, should consider the 4 questions on Page 22 of the case study and be prepared to discuss their answers. Professor Moe

will “cold call”!

Liz Charles is a nurse and candidate for the Masters in Business Administration, Fuqua School of Business, Duke University (Health Sector Management concentration). As an IPIHD intern she spent 21 days on site with various One Family Health franchisees and leadership in July 2012. A desk audit of materials provided by OFH before her onsite engagement and her observations and interviews in Rwanda are the basis for the case study. Jeffrey Moe is an Executive in Residence and Adjunct Associate Professor, Fuqua School of Business, Duke University. Richard Bartlett is the Associate Director of the International Partnership for Innovative Healthcare Delivery

1 The International Partnership for Innovative Healthcare Delivery (IPIHD) was founded by the World Economic Forum, McKinsey and Company and Duke University. IPIHD aims to identify, learn from and provide practical support to scale and replicate successful models in healthcare delivery. IPIHD has a social mission of increasing global access to cost-effective and high-quality healthcare, and believes this achievement is a critical component to reducing inequities in healthcare delivery around the world. www.ipihd.org

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Acronyms

ADDOs Accredited Drug Dispensing Outlets CAMERWA Consumables and Equipment Central Procurement Agency CFW Child Family Welfare GSK GlaxoSmithKline HSF Health Stores Foundation IFC International Finance Corporation IPIHD international Partnership for Innovative Health Delivery MDGs Millennium Development Goals MOH Ministry of Health NGO non-governmental organization OFH One Family Health PPIP public-private investment partnership PPP public-private partnership

SHF Sustainable Healthcare Foundation

Executive Summary The One Family Health (OFH) posts are organized as a franchise network of health “posts” operating in urban, peri-urban and and rural Rwanda. The posts operate as a first “touch point” for patients immediate and most common care needs (e.g. malaria, child diarrhea) and relieve high demand on community health centers. The vision is to establish 500 posts by 2019 supported through a public private partnership (PPP) which includes One Family Health (OFH) Foundation, GlaxoSmithKline, Ecobank, Healthstore Holdings (HSH) and the Rwandan Ministry of Health. Each post is run by an experienced nurse who has access to financing and training in business, post operations and clinical skills. The franchise approach allows the nurse operator to earn a living while increasing access to essential medicines and basic healthcare for under-served communities. Posts are typically capitalized by loans made by local Ecobank branches to a nurse franchisee. After a short grace period the posts begin paying back the loans and operate on a self-sustaining basis. The physical structures are provided by the local communities. OFH posts can accept patients who have coverage under Rwanda’s community-based health insurance scheme, the Mutuelle de Sante

which covers ~90% of the population. The posts have electronic record keeping, inventory/supply chain and performance monitoring capabilities provided through the internet-based LifeQube system. LifeQube links into Rwanda’s national electronic health record system which allows the Ministry of Health to monitor disease states of particular national interest (e.g. malaria) and areas

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of national focus (Vision 2020 goals) which are related to Millenium Development Goals 4, 5, 6 (maternal health). OFH is deploying a hub and spoke management system and expanding its supply chain to service a growing network of posts. As an IPIHD innovator, OFH is capturing evidence that which increase in sophistication along a developmental pathway allowing a future evaluation of the performance of the OFH post network including an assessment of health status outcomes. 5 categories of challenges face OFH as it works to meet its aggressive scale up plan. The challenges were identified during a July 2012 site visit by an IPIHD intern which fall into 5 broad categories: 1. Human Capital/Education and Training, 2. Supply Chain Management, 3. Staff and Revenue Management, 4. Post Performance and Evaluation, 5. PPP Collaboration and Local Expectations. Background Health care in Africa The IFC starkly described health care in Africa as “the worst in the world” and suggested that “$25 - 30 billion in new investment will be needed in health care assets” over the decade 2006 - 2015. i Such a dire assessment and daunting forecast requires innovative health care financing and delivery solutions. Innovation is occurring ii through novel private sector approaches which according to one study included “social marketing, cross-subsidization, high volume/low cost models and process re-engineering.” iii One particularly robust innovation over the past two decades has been creating drug shops in urban and hard-to-reach rural locations, frequently through franchising schemes. Included in these new approaches to delivery are financing approaches that bring together public and private sectors through public private partnerships (PPP). Public Private Investment Partnerships are a special form of PPP’s which “leverage private sector expertise and investment to serve public policy goals - specifically the provision of high quality, affordable preventive and curative care to all citizens.” iv While the long term nature of the partnerships can strain the patience and skill of the partners, much work has been done in African countries, including Kenya and Rwanda, to allow such partnerships to exist, through statutory and regulatory reforms.v Medicines and associated consultations/diagnosis for those treatments are sold through small shops, often under a franchise ownership arrangement, in many areas of East and West Africa. Such chains operate in Cameroon, Eritrea, Ghana, Kenya, Nigeria, Tanzania and Uganda. Formal pharmacies are very limited in number in population centers and especially scarce in rural locations. Drug shops, which frequently also sell other household goods, serve as an alternative and fill the gap created by the lack of formal pharmacies. The ADDO initiatives in Tanzania have demonstrated that a network of individually owned drug shops can grow in number, penetrate hard to reach regions and displace shops with lower quality services and products. vi The franchise drug shop approach, while growing in low income and emerging markets, has raised concerns among observers regarding uneven quality of product and service offerings, poor training of franchise owners, non-compliance with pharmaceutical regulations and overall concern that profit motivations overpower commitments to quality. Studies have suggested that policies and practices can be developed to address these concerns including a call for public-private collaborations. vii Like many comprehensive reforms or even smaller scale innovations, drug franchise shops face the problem of infinite needs against finite resources or the iron triangle of health care: balancing cost, quality, and access goals. It’s difficult to achieve any two outcomes in the triangle; meeting all three has proven to be extraordinarily difficult whatever the reform or innovation. For example, ADDO is

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a replacement for the severe shortcomings of the duka la dawa baridi drug shops found in urban and peri-urban Tanzania. Creating a network of shops offering affordable medicines in urban and hard to reach locations meets two of the criteria: cost and access. While making strides to improve quality as compared with its predecessor, it has proven more difficult to also make quality improvements. Evaluation reports continue to find gaps: staff without proper certifications and training, stocking of unapproved medicines and overall lack of regulatory compliance. viii

Recent political and health care history in Rwanda

Since seizing control in 1994, revolutionary general Paul Kugame began shaping the country’s future which included addressing significant healthcare gaps, historically endemic to the country and exacerbated by the civil turmoil in the early 1990’s leading to Kugame’s takeover. Kugame sponsored a national consultative process (1997-2000) that resulted in a comprehensive national development plan entitled, Rwanda Vision 2020,ix a document that serves as a framework “to transform [Rwanda] into a middle-income nation in which Rwandans are healthier, educated and generally more prosperous.”x

Over the past decade Rwanda has moved towards these goals, making progress towards meeting the Millennium Development Goals which are incorporated into 2 key health planning documents: Health Sector Strategic Plan (HSSP) and its 2008 revision, HSSP-II.xi The HSSP guides the action of the Rwandan Ministry of Health and acts as a framework for reforms and intervention. The 2008 revision (HSSP-II) places increased emphasis on family planning, non-communicable diseases, prevention and human capital improvements

The State of Health in Rwanda In 2011 Rwanda’s population was 11.6 million, the

majority of whom (81%), lived in rural areas. Four

percent of rural homes had electricity, compared to

45% of urban residences. The GNP per capita was

$1300, average life expectancy at birth was 58 years,

the child mortality rate was 92 per 1,000 live births,

HIV prevalence was 2.9% and 50% of the population

had access to sanitation facilities.1 (Compare with the

US where GNI was $48,100, life expectancy was 78

years, the child mortality rate was 8 per 1,000, HIV

prevalence was 0.6% and 100% of the population had

access to sanitization facilities). The total Rwandan

expenditure on health as a percentage of total public

expenditure was 10 percent (2010, US 18%)1 and the

total expenditure on health per capita was $56 (2010

data, US $8,362).1 1 1

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HealthStore Foundation - CFW - One Family Health (OFW) In 1997 Scott Hillstrom founded HealthStore Foundation organized as a non-profit with the mission of “improv[ing] access to medicine and basic healthcare services for children and families in the developing world.” Under the auspices of HealthStore, Hillstrom developed the Child Family Welfare Shops (CFW) brand, a network of for-profit, franchise-owned health clinics and drug outlets, to further the mission. In 2008 Gunther Faber was hired as CEO of Health Stores Foundation and the CFW brand. After partnering with the Kenyan non-profit, Sustainable Healthcare Foundation (SHF), this hybrid profit/non-profit model had prospered, empowering women and communities, and delivering basic life-saving care.xii In April of 2012, Faber and Dr. Agnes Binagwahi, the new Rwandan Minister of Health, concluded discussions to add franchise nurse run clinics operating as One Family Health (OFH) into the government’s strategy in achieving their Vision 2020 goals. The OFH posts are organized to operate as a franchise network. Each post is run by an experienced nurse providing an entry point into the Rwandan public health system. This franchise model gives nurse-operators access to financing and training in financial management, operations, logistics, etc; allowing him/her to earn a living while increasing access to essential medicines and a first touch

Human Resources for Health

The World Health Organization (WHO) considers Rwanda to be one of 57 countries worldwide with a

critical shortage of health workers. 1

633 Rwandan physicians, 6,970 Rwandan nurses (90% with the

lowest level of nurse training available), and ten Rwandan dental surgeons serve the entire country

(nearly 11 million people).1 Health worker density is 0.72 per 1,000 persons, (WHO minimum density =

2.32)1 and most districts have only two doctors per 100,000 people, well below the WHO suggested

minimum, and the Vision 2020 goal, of ten medical doctors per 100,000.1

Rwanda’s Human Resources for Health Program aims to address these concerns “by dramatically

increas[ing] the number, quality, and skill-level of Rwandan clinicians and health sciences educators,

including medical doctors (general practitioners, specialists, and subspecialists), nurses and midwives,

and oral health professionals.” This substantial scale-up will be achieved through an unprecedented

collaboration between 19 of the top US educational institutions and the Rwandan Ministry of Health with

funding supplied by the US government and the Clinton Health Access Initiative.

Through the HRH Program, the Government of Rwanda aims to upgrade infrastructure and equipment

and improve teaching, research and curriculum development. Each US University will contribute full-

time faculty to help build internal capacity and self-sufficiency within an eight-year time frame. After

this point, US faculty and financial assistance will be phased out. The Rwandan Government will directly

oversee the HRH program with the goal of minimizing inefficiency, improving accountability and

streamlining coordination.

The hope is that central oversight will reduce overhead costs, standardize contracts, and curtail

paperwork. The Government is to supply medical licensure, malpractice insurance, and a housing

allowance while the University recruits and employs professionals for a minimum one-year residency in

Rwanda. Currently (June 2012) the tangle of logistical and legal inputs threatens the August launch of

this groundbreaking undertaking.1

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point for basic healthcare in local communities. The Ministry of Health accepts National Health Insurance claims (Mutelle) made by patients through the health posts. The approach is organized as a public private partnership bringing together One Family Health (OFH) Foundation, GSK, Ecobank, Healthstore Holdings (HSH) and the Rwandan Ministry of Health. The aspiration is to establish 240 health posts over the next three years (2012-2015) reaching a total of 500 by 2019. GSK has committed £900,000 ($1.4 million) to HSH to finance an initial 60 health posts. Under the terms of the partnership, GSK will provide £1.8 million ($2.8 million) in new funding as an interest free loan to finance an additional 180 health posts. The Rwandan Ministry of Health and/or local communities will provide the physical structures for OFH Health Posts. Ecobank will provide loans at affordable rates through donor subsidies to support local franchisee nurse-operators start-up costs. Both GSK and Ecobank will fund continued nurse training and development. HSH has agreed to provide ongoing training, mentoring and expertise to support the nurse franchisees. Nurse Franchisees OFH local delivery of products and services begins with the recruitment and training of a nurse-franchisee. Rwanda, like much of Africa suffers from a healthcare worker shortage.xiii To avoid draining the public health system of its most experienced and well-trained nurses, and as part of the PPP agreement, OFH agreed to restrict their franchisee hiring to “A2” nurses (the entry-level nurse). With three years of specialized secondary school training, these nurses are taught a broad spectrum of skills, which include wound suturing and the insertion of family planning devices (such as IUDs and implants), and are given prescribing authority over a variety of medications. However, as OFH

Shops began hiring these nurses, they also found a broad spectrum in their true clinical abilities. Variability in diagnosis, assessment and treatment was partly overcome by limiting services and products (to address only the most common, preventable and treatable diseases). The lean design ensures ease of clinical

diagnosis, streamlines the use of protocols, simplifies drug regulation, and leads to more consistent quality. Variability was further addressed through the development of an electronic platform, which would guide the nurse through the patient visit and help manage the clinic.xiv Nurses are recruited through various sources; local newspaper ads, word of mouth, postings on job boards at district offices and through local administrator referrals. According to the PPP only the lowest level nurses may serve as franchisees. Therefore applications indicating otherwise are immediately rejected. The application process includes submission of CV and letter of intent. Because the postal system is not developed, most applications are hand delivered to the main office or arrive via representative with regular OFH contact (e.g. current franchisees, or government representatives). Applications are screened according to educational background, exam scores, personal references and work history. Accepted nurses are kept in a potential pool of candidates. As sites are identified the pre-screened nurses are notified through SMS text messages. They are invited to visit the sites and send notification of interest to the Training and Compliance Manager.

Nurse Qualification Level Number A0 (Bachelor’s equivalent) 20 A1 (Some post secondary education)

457

A2 (Three years secondary education)

6152

Grand Total 6629 Source: DHSST, Dec 2009

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Interested nurses are interviewed and given both oral and written examinations to assess clinical knowledge as well as inter-personal aptitude. Orientation for new franchisees is held once a cohort of 5-10 is established. The nurses attend two-weeks of orientation. The first week is broken into one day of business and financial training, one day of technical and logistical training and three days of nursing and compliance training from the corresponding managing director. Franchisees are trained in record keeping, diagnosing target conditions and accurately prescribing medicines. In the second week nurses are placed in existing clinics to shadow and learn from current franchisees. Nurses also receive three manuals:

Operations manual: OFH Posts policies and procedures for health services, operations, drug management, financial business management, staff management, training and education, marketing, and leveraging the advantages of a franchise system. Treatment guidelines: Reference guide for diagnosing and treating the most common ailments seen at OFH Posts in Rwanda. Essential Medications: Approved drugs and reviews instructions for use; drug descriptions, indications, common dosages, side effects, when drugs cannot be used, and other relevant notes.

During the orientation process, the franchise agreement, which includes an obligation to protect the OFH Post brand through strict compliance with the operating standards, to use only OFH approved products, to ensure employees are properly trained and clinics are appropriately staffed, and to promote the clinic according to HSH guidelines, is officially agreed to and signed. At this time the nurses must show proof of down payment (bank slip indicating $500 deposit to OFH account). Electronic Health Record OFH contracted LifeSense (LifeQube), a South African software design firm founded in 1991, to design a disease management and data collection platform similar to the projects they had designed in Namibia, Swaziland and South Africa and modeled on Kaiser Permanante’s (US “staff model” health maintenance organization) integrated health system.

LifeSense’ system is lightweight with cross mobile program capabilities currently available on low-cost Nokia series 40 devices and low cost android based devices. The system is internet-based and thereby eliminates the dependence on and costs associated with mobile operators SMS and USSD infrastructure.

In 2011, the LifeQube system went live in Rwanda. The LifeQube platform enables OFH franchisees to gather and send data to and from their

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clinics using cellular (http or https) technology. The LifeQube system in turn assembles the data into an Electronic Healthcare record, allowing real-time monitoring of each clinic’s financial dynamics, drug utilization, stock control, and disease management. Among other benefits, the LifeQube system deployed in Rwanda supports health insurance claims processing, enabling access to the national health care system (which is still under development).xv The system also generates detailed reports for government and donor use, includes medical savings account mechanisms and is flexible enough to permit other systems to plug in to the system to conduct pricing studies or trials in a closed network. Franchisees can also manage clinic expenses, salaries and banking information using the phone. Patient and user information is not stored on the phone, but is sent to a secure data center hosted by ISP.*

Rwanda’s public sector is moving from a paper to an Electronic Medical Record system. OFH’s HER feeds into the national system and allow continuity of care and sharing of health records at all levels of the health system.

Patient’s visiting the clinic for the first time present their Mutuelle Insurance cards. Their name and ID number are typed into the phone, a picture in taken, and then vital signs, symptoms, and tests are entered, as well as the diagnosis and batch numbers and expiration dates of any medical items used or dispensed. Patients are assigned a health record number, which when entered during subsequent visits, retrieves their medical history and helps by-pass the initial intake steps. Franchisee Continuing Education Each nurse is further expected to attend a minimum of five days of OFH Post sponsored training each year. These events, usually two-day workshops, are held quarterly. Using the conference facilities of local hotels, nurses gather for presentations by the management team or external trainers. Topics include policy updates, review of problem areas, LifeQube (EHR) platform changes and the strengthening of financial understanding (how to correctly build the P&L, manage inventory, keep a business bank account, etc.). Local officials and guest speakers address concerns on topics such as the reimbursement process, and rapid malaria quality control testing. Lunch is included and the nurses enjoy the company of other franchisees.

Continuing education plans also include a regular newsletter to be distributed to franchisees with further training help on issues such as proper medication use, disease treatment protocols, and business management and inventory tips. The first such newsletter is under development at this time. OFH also hosts an annual conference, mainly for the opportunity to build collegiality and recognize excellence.xvi At this event, the nurse franchisees elect one of their peers to serve as the representative to management (one-year term). All concerns, complaints or questions are filed through this representative who acts as the gatekeeper and mouthpiece, delivering information to and disseminating information from management.

Most Commonly

Treated Illnesses: Malaria, diarrhea,

malnutrition and

bacterial infections,

upper respiratory

infections, skin disease,

accidents, hypertension,

eye infection, pregnancy

related conditions,

parasitic worms and

bone and joint disease.

Source: HBS CFW Shops Case,

2011

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Services Offered By offering a limited choice of services and products (mainly aimed at the most common, preventable and treatable diseases), OFH creates a lean design that ensures ease of clinical diagnosis, streamlines the use of protocols, simplifies drug regulation, and leads to more consistent quality. Having tight bounds on the scope-of-practice also aids in the monitoring of operations and processes.xvii Among the commonly treated illnesses, malaria, diarrhea in infants and children and malnutrition are the initial areas of primary focus at the posts. Clinics are required (per the franchise agreement) to be open a minimum of six days a week from 8a.m. to 5p.m.. Because electricity is not available in many locations and because the sun sets around 6pm, evening clinic hours are rarely implemented. Most franchisees have employed a second nurse to allow for days off. OFH has not asked for permission to provide laboratory services at the posts because of the additional compliance and regulatory burden. Only rapid screenings are performed (e.g. rapid malaria, rapid chlamydia and rapid pregnancy diagnostics). This maintains a focus on providing the most basic and essential care and puts bounds on the knowledge necessary for provision of care by franchisees. Inventory and Logistics Management At the end of each month, franchisees are required to complete a thorough stock count, which is reconciled with the electronic record. New orders are placed via the phone and are ideally based on average monthly usage and maintenance of an ideal safety stock equal to one month’s supply. From headquarters the Logistics and Technical manager is able to monitor clinics in real-time Per the PPP agreement, OFH uses the government’s Consumables and Equipment Central Procurement Agency (CAMERWA) for customs clearance, storage and distribution of supplies. If CAMERWA is unable to complete an order or if OFH obtains better pricing through the outside market, OFH can enter into a contract with an outside supplier, as long as that organization makes the item available to the government on similar terms.

For items unavailable at the central pharmacy,Posts currently uses two local suppliers (Abacus and Ubumwe). Supply chain integrity is an issue for pharmaceutical users across Africa, where regulatory and enforcement agencies are weak. The prevalence of substandard and counterfeit drugs is a public health concern resulting in treatment failures, increased resistance and deathxviii. To combat this, OFH would prefer to source through one single, reputable supplier and is currently investigating two options: 1) contracting with Surgipharm, the distributor for CFW Shops in Kenya or 2) sourcing through a German operation [NAME?}] to ship bi-annual purchases stored in the central pharmacy and distributed monthly as needed. CAMERWA will dedicate a portion of their warehouse space to OFH clinics and oversee customs clearance of the supplies. CAMERWA will continue to distribute the supplies to its regional hubs where, once large enough, OFH field officers will complete the dissemination. Field officers will take over some of the inventory responsibilities now assumed by the Logistics and Training manager. Currently from the central offices, the Logistics manager reviews the

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franchisees’ orders, making sure the orders match demand planning forecasts to ensure in-stock availability and to prevent overstocking. Once approved the orders are combined and sourced from distributers. Lead time from the two private suppliers is a couple days, while CAMERWA lead times are closer to two weeks. After receipt, medications’ batch numbers, expiration dates, and costs are entered into the EHR. Invoices are created and the manager sorts the medications by clinic before they are delivered (using a branded 4x4 pick-up truck with covered bed). Delivery to the ten clinics in and around Kigali is completed over a three-day period. Upon delivery the nurse franchisee re-counts each medication, double checks batch numbers and expiration dates and certifies receipt from the delivering agent. The order costs, which for the franchisee includes a five percent mark-up, are deducted from his/her next Health Insurance reimbursement payment. Revenue Also captured by the electronic health record are the costs associated with each patient visit. Clinic revenue is generated through claims processing by the National Health Insurance system (Mutuelle), which boasts coverage of over 90% of the population. Mutuelle reimburses clinicians according to their skill level and a set list of procedures and medication/supplies. The OFH patient intake and service documentation procedure captures the needed claims information and organizes it by clinic and cell location. Each month, the claims, which consist of line item accounts of each patient visit: name, health insurance number, diagnosis, treatment received and reimbursement fee (according to the pre-determined Mutuelle price list) are hand delivered in hard copy to the district offices by the OFH Posts’ Accountant. District administrators further distribute the claims to the appropriate sector where Mutuelle representatives, in addition to their full-time assignment, review each visit for accuracy of enrollment, treatment, and reimbursement prices. Disputations (less than 5% of claims) are directed to the OFH Accountant, who investigates the challenged claims with the appropriate nurse franchisee or manager. Once claims are approved, notice is given to the district office and money is credited to OFH account from each sector’s bursar account. To simplify the procedure, Life Sense is currently creating a portal whereby the Mutuelle claims representatives can access the needed information directly through the LifeQube system in view-only mode.

National Health

Insurance Instituted in 1999, Rwanda’s

community based insurance

program, the Mutuelle de Sante,

reaches nearly 90% of the

population.1 Autonomous

organizations at the village and

district level pool financial risk

(excessive needs, greater than

$5000 are covered by the

central government). Each

citizen depending on income

level is required to contribute

between 2000–7000 Rwandan

Francs (3-12US$) per year and

pay a 200 RWF (0.35$US),

upfront, co-pay for each

hospital or health center visit.

Decisions, including deciding

who is too poor to contribute,

are made through an elected

village committee. Donor

subsidies cover the yearly dues

of those nominated for an

exemption. Estimates suggest

that 10-30% of the population

has their fee waived and

administrative costs represent

5–8% of the total revenue.1 1

Though modest, the yearly

Mutuelle insurance fee of $2 is

still beyond reach for many of

the rural poor, and is

insufficient to fund the basic

services (actual costs range

from $14-$20 per person).1

Substantial government funding

and donor contributions (about

a 50/50 split) are necessary.

The government’s recent

supplementation of Mutuelle

with contributions from other

insurance programs has helped

improve the programs stability.1

1 1 1

http://focus.rw/wp/2011/07/new-mutuelle-

policy-higher-fees-for-increased-coverage/

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Finances: Revenue per visit, profits, loan repayments OFH forecasts that each franchisee can realize $6,000-$7,000 profit/year; $3,000 ongoing fees and product margins. Clinics are projected to reach $20,000 sales/year: 33 patient visits a day with average revenue $1.98/transaction, to reach the profit and fees forecasts. With a down payment of $500 (which can be provided as a loan from EcoBank) franchisees qualify for an OFH sponsored loan for the remaining start-up costs (between $5000 - $8000 for remodeling costs, furnishings, inventory, licenses, staff wages, and utilities). Funding for the loans is derived from the three years of seed funding donated by GlaxoSmithKline. Monthly loan re-payments, which range between $85-$140 are deducted from the Mutuelle Health Insurance reimbursement checks along with any drug costs (inclusive of 5% markup), a royalty and marketing fee equivalent to 8% of clinic revenue, and any cash advances made (a practice, that in general, is strongly discouraged). The 5% mark-up on drugs covers the cost incurred in ordering, sorting and delivering the medications to each clinic. The royalty and marketing fee is allocated as 6% royalty and 2% marketing. Failure to repay the loans results in a series of remedial actions which may result in loss of franchisee’s right to clinic ownership. All terms are stipulated in the loan agreement. Each month the OFH accountant prepares a report of the previous month expenses and creates a cash projection for the upcoming month. The in-county manager and finance director review this report before submitting it to the OFH Board of Directors for final approval. OFH Management and Organizational Structure In-country activities are overseen by a UK based board-of-directors (also organized in the US as a 501(c(3)) which includes the OFH CEO, Chief Operating Officer, a Financial Director and an administrative assistant. OFH has assembled a small management team: In-country manager (or “franchisor”), Accountant/ Logistics/Technical manager, Training and Compliance manager, and part-time Financial Director. The OFH structure places a layer of management between the central office and the franchisee: a Field Officer (FO). The franchisee and his/her Field Officer face the daunting challenge of inadequate roads and infrastructure, seasonal storms which can drastically affect the ease of delivery and maintaining the stability of temperature-sensitive medical supplies. The plan is for FO’s to mange 10-20 clinics in a hub and spoke structure. The FO will distribute from the regional offices using a motorbike (with attached fiberglass box for medications) that can traverse hilly, un-developed roads. FO’s will direct the franchisee and assist him/her to complete compliance checks. At the time of this writing, the first FO positions are being filled. Compliance Once settled in their clinic, the franchisee can expect regular visits from the Compliance Manager, who visits new clinics every month for the first three months and then quarterly thereafter. The visits, announced or unannounced, are an opportunity for the manager to assess compliance with a list of pre-selected policies taken from the Operations Manual: correct documentation, proper handling of dirtied equipment and general appearance and cleanliness of the clinic. After walking

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through the clinic together, the compliance manager sits down with each nurse, allowing the franchisee to self-grade her performance, answering questions and pointing out areas of concern. Issues that are not up-to-standard are noted and checked during the following month’s compliance review. Failure to comply triggers a corrective action plan that nurses agreed to upon signature of the franchise agreement. Community Engagement Marketing of the clinics is facilitated through strong ties to civil society, limited mobility (few competitors as local patients do not travel to other locations for health needs) and a culture of community engagement in local political and social activities. Mandates from the highest levels of the Health Ministry incent local leaders to support the health posts as official entry points into the health system. Community Health Workers and the Community Centers have both been instructed to refer patients to the OFH posts. The plan is less acute cases will be treated at OFH posts while more critical cases will be directed to the comprehensive clinics. Rwanda is largely a “walking culture.” Outside the city centers few cars or public transportation options are available. The limits on mobility create tight knit communities where word travels quickly. The arrival of new OFH Posts is welcomed for its proximity but also for its acceptance of Mutuelle insurance, which makes medical care affordable. A patient co-pay, 200 RWF provides a nurse consultation and treatment if indicated. To access the same health services in say Butare or Gisenyi (larger cities in Southern and Western provinces respectively) would require many hours of walking from a rural location or the additional cost of a moto taxi, a minimum of 500 RWF. Communities across Rwanda meet on a weekly basis in traditional village meetings, the main forum for information sharing from government leaders. In addition, on the last Saturday of the month, the larger sectors gather for a day of service called “Umuganda.” After clearing bush, picking up litter, digging trenches for several hours, the community gathers, one representative from each household by law must be present, to discuss issues affecting the larger population. Through these events people can access authorities to articulate their needs and voice opinions on various issues. Both of these events provide an opportunity for the franchisee to engage local leaders and stakeholders in the community, promote their services, build rapport and impart public health knowledge. Coordinated by the Training and Compliance manager, nurses introduce their clinics at these events and thereafter provide education training on topics relevant to the population. Competition Most for-profit health care providers target middle to upper income patients and therefore do not pose a threat to the OFH model. However, there are health care non-profits working in some communities. The not-for-profit providers must meet government regulations regarding the size and type of services offered. They can offer highly subsidized or free care for some services making them a formidable competitor to OFH’s offering. When such non-profit competitors are in a community, OFH Posts are not placed in those locales.

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Traditional health still has a moderately strong presence in Rwanda. Historically high costs of healthcare drove patients to those healers. A social health insurance scheme and increasing experience with “western medicine” is offering patients an affordable alternative to traditional healers. Upon signing the PPP agreement, the government agreed to stop expansion of their health posts, which eliminates the existence of direct competition in the public sphere. The MOH is actively encouraging use of OFH as the first point of care. The next level of care after the OFH post is a community health center. Nurses in the health post are expected to refer cases beyond their ability to treat to these community centers. In areas where posts operate, the community centers have welcomed OFH Posts’ services as the initial entry point for patients. The addition of Posts has led to a reported reduction in patient visits at community health centers, resulting in more manageable levels of patient demand. Community centers are managed by A1 nurses (3 years of post-secondary training) and staffed with eight to ten A2 nurses, midwives and several adjunct health workers. The centers house a laboratory for more in-depth diagnosis and a refrigerator for storing cold chain medications (e.g. vaccines). The clinics have beds and are able to monitor patients overnight along with a labor and delivery ward. A doctor typically visits the community clinic on a weekly basis. The community clinics are set apart by their ability to offer family planning and vaccination services free of charge. Through partnership with The Global Fund, the needed materials are donated and the nurses administering the services are given financial incentives for their implementation and use. These bonuses help retain and motivate nurses working in the public health service. OFH shops are not authorized to receive the same benefits and therefore administer family planning services at cost (supplied by PSI at reduced rates) and do not offer immunizations. Expansion As part of the PPP each district must request the expansion of the OFH Shops into their area. This request follows the prioritization of healthcare within the district and an associated willingness to direct resources to this aim. The district locates potential buildings for use by the health post. Structures must include a waiting area, consultation room, procedure room, pharmacy storage area with locked door, and toilets. Electricity is desirable, but can be circumvented through use of a pressure cooker to sterilize equipment. Clean water access is also important and at clinics where this has been a concern, OFH has helped create storm water collection systems. A final consideration is the quality of cellphone reception. Dashboard not available to the franchisee because of no laptops; not familiar with how to use laptop Once a district identifies several possible site locations, members of the management team visit the sites accompanied by a district representative. Determination of site suitability can be made on-location. Any remodeling costs (e.g. creation of room partitions, laying a cement floor) are assumed by OFH and are added to the loan amount associated with that clinic. Site selection is also influenced by population catchment (a minimum of 5,000) and if a competing NGO drug shop/clinic is operating in the same area. Most sites selected to date have not required significant upfitting and are parts of existing government offices or school buildings. For example following a recent exploratory visit to the

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Eastern District of Gatsibo, 19 sites were visited: ten were ready for immediate use, four needed minor remodeling, one was too close to another site; leaving four that were unsuitable or required extensive remodeling. After sites are finalized a memorandum of agreement is drawn and OFH officially enters into a partnership agreement with the Local District Administration. OFH contracts local tradesman to remodel the posts as necessary and sources the necessary furnishing (tables, chairs, examination tables, autoclave, water basins, etc.) using local craftsman as able. Community discussions are a reliable venue to receive feedback to OFH franchisees. Rwanda enjoys a culture of candor and honest responses to sincere inquiries regarding performance. Franchise operators who use the community forums have a low-cost and reliable mechanism to gather patient satisfaction and performance improvement information. Monitoring Performance OFH’s monitoring program captures performance information using the LifeQube platform. Once on line, a “dashboard” appears on screen which is a snapshot of current clinic activity: # of patients seen (daily, weekly, monthly), length of consultation time, receipts, staff hours worked. Additional information is available at the “next click” level: historical reports by gender, rank order of diseases diagnosed. A malaria-specific report is provided to the MoH which tracks malaria diagnoses, medications provided, malaria medicines in stock, etc. The LifeQube system has the capability to initiate an email to the franchisee and the OFH management team if specified critical levels are reached: low stock alerts, inventory levels, or unusual events (significant change in # of patients seen). A “balanced scorecard” approach is in development to provide a comprehensive weekly snapshot of financial and non-financial performance indicators for use by the franchisee and OFH management. The balanced scorecard was introduced by business Professors Kaplan and Norton which has grown in use and popularity to be supported by its own institute which provide organizations measures of financial and non-financial performance “to align business activities to the vision and strategy of the organization, improve internal and external communications, and monitor organization performance against strategic goals.”xix The method is widely used and has been applied to health care in low resource settings. Traditionally medical records are paper based in Rwanda. Acceptance of electronic information capture using phones and other non-paper devices requires time for acceptance and facility with the equipment. Internet connectivity is provided through cellular data networks. These networks can operate slowly or fail for short periods of time. This data and communication infrastructure weakness creates a barrier to adopting the monitoring system; temporary paper records maintains a psychological link to the paper-based tradition of medical record keeping. IPIHD and OFH have been collaborating on a streamlined and updated electronic dashboard which will give the nurse franchisee a broader profile of key performance indicators. The illustration below depicts indicators and their visualization that is currently under development (for illustrative purposes only).

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IPIHD approach to evidence development and evaluation Innovation is occurring in the private and public health sectors. The majority of these innovations in delivery of health care services have not reached full scale and rarely cross borders for replication in another national setting. Unfortunately the accounts of these new approaches is largely anecdotal and relieves heavily on self-reported data. The Center for Health Market Innovations (CHMI) serves as one repository of innovations like OFH. IPIHD assumes that one significant barrier to full scaling and innovation replication is the lack of evidence and objective evaluation. IPIHD has developed a developmental continuum of evidence/evaluation.

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Innovators find themselves at varying levels of evidence development. This is due in part to the maturity of the innovation, the type of innovation (e.g. in-patient v. out-patient) and the resources available for capturing and analyzing evidence/evaluation data. IPIHD works with its innovators to establish a developmental path leading from basic measures of evidence to assist in performance management and communication to internal and external audiences. From performance management evidence, a developmental path exists on a continuum moving toward more robust evidence which can support an objective evaluation of health outcomes for individuals and served populations. There is no one developmental path or evaluation “formula” applicable to all innovators. The nature of each innovation necessitates a unique approach to evidence and

Internal Self-reported

Subjective

External Other reported

Objective

Innovator performance indicators

Patient/Population

Health status

Risk Reduction and/or

Patient Satisfaction

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evaluation. It is expected that similar innovations will likely follow similar paths of evidence development. The goal of moving along a developmental pathway is not to satisfy a publication criteria or establishing funding worthiness. IPIHD and its innovators pursue increasing evidence development so the innovation can realize its full potential and support replication in other settings. This goal is in the self-interest of the innovator and IPIHD. While evidence is developed, some causal linkages can be suggested to show how and to what degree making a health post available, for example, to under-served patients changes access, costs and quality of care provided. These “iron triangle effects” suggest how resulting changes in the health status of the populations served, changes in risk reduction and/or patient satisfaction with the services provided occur. Increasing evidence helps understand and ideally, ultimately show, the relationship among the innovation’s unique constellation of product and service and health oucome effects. A full blown “impact evaluation” with robust information with some likely causal linkages identified requires years of effort and significant financial investment. Short of these full evaluation methods, there are evidentiary approaches that can approximate and give guidance to innovators, funders and partners on the health outcomes which have resulted from the innovator’s activities. OFH, like many early innovators, is fully engaged in the challenges of finding new locations for posts, selection and training of nurse franchisees; operating the post through effective interaction with patients, summarizing daily/weekly activity, re-supplying medicines and paying back start-up loans. Added to that weighty demand on scarce resources is a commitment to gather initial evidence of performance. Innovators assume additional technical support will be provided to assist them in meeting their performance objectives while moving along the evidence and evaluation developmental pathway. (see “The Way Forward” below) NOTE: IPIHD is currently developing a white paper describing its approach to the “evidence to evaluation developmental pathway.” Challenges OFH faces a variety of challenges as an innovator combining a novel delivery of services model with an innovative financing scheme bringing together the public and private sectors through the PPP. The challenges fall into five categories: 1. Human Capital/Education and Training 2. Supply Chain Management 3. Staff and Revenue Management 4. Performance and Evaluation 5. PPP Collaboration and Local Expectations. Human Capital/ Education and Training Clinically, there is a wide variety of abilities regarding diagnosis, various treatment interventions, medical knowledge and access for consultation. Overall, franchisees vary widely in the 3 capabilities areas required for successful franchise operation: medical, business, and technological (ease of engagement with the electronic platform). Initial training attempts to bring all franchisees to a minimally proficient level in the 3 areas irrespective of their capabilities at hire. Given a short training regimen it has been challenging to

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teach necessary skills in short time. The difficulty of meeting the training commitment will be exacerbated by turn-over, new hires leaving or being replaced, and the daily demands of successfully operating the franchise and some nurses interest in clinic ownership and management while continuing other jobs in hospitals, or marketing. OFH plans to be more discriminating selection of franchisees requiring proficiency in areas other than nursing; and the training may become more individualized to close the gaps unique to each franchisee in addition to the training challenges. Continuing Education The training sessions vary by the skill level of the trainer: some pace the training too slowly; inefficient use of time. In addition to the training OFH offers newsletters but it is unclear who is the intended reader, how didactic should the content be and if materials should be translated into multiple languages (English, French, Kinyaarwanda). Beyond skills training there is a perceived need to continue supporting/encouraging entrerpreneurial attitudes and collaboration. The newsletters and continuing education resources are provided to the main nurse franchisee, however it is unclear if she in turn makes the resources available to other workers or if she uses the newsletter information to do on the job training for others in the post. There is no systematic evaluation to determine what skills transfer from the classroom training and/or newsletters to new knowledge, skills and abilities in the post. Health workforce shortage exacerbates high demand for priority maternal and children’s health services Priorities and special incentives have been placed on maternal health (e.g. family planning) and children’s health services (e.g. immunizations) by the MOH and Global Fund. The delivery of these priority services often do not meet targets and demand due to restrictions in service provision to Community Health Centers. In rural areas patients cannot travel to distant community centers and outreach vehicles may not connect with patients frequently enough to meet needs. OFH is more accessible but at present cannot provide these maternal and child services per terms of the PPP. Supply Chain Management Challenges: Electronic Order and Re-Supply The electronic process of stock ordering and delivery is time consuming for the manager. Franchisees place orders which the Logistics and Technical manager checks line-by-line. Medications received are entered line- by-line with invoices created in the same fashion. Each process requires 2-3 days of data entry. The logistics manager has suggested it would be more efficient if she placed orders for each clinic. However, this may distance the franchisee from

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monitoring and participating in the mission critical task for re-supply and invoicing. Using three drug distributors may not be sufficient: stock outs of most popular medications are a high priority to be avoided. Stock outs will likely be exacerbated as the number of franchise clinics increases unless additional, reliable suppliers can be added. While franchisees continue to do their own auditing and ordering, the efficiency of the overall re-stocking system is limited by franchisees who perform the task inaccurately and/or in an untimely fashion. Challenge: Sourcing enough medication and timely dissemination to rural outposts Securing a continual supply of drugs, even on a small scale of ten clinics, has, at times, been challenging for OFH. As the model grows, this will only become a greater challenge. Working toward smooth inventory management with consistent ordering practices and efficient dissemination of supplies will become increasingly a challenge as the organization grows in size. Staff and Revenue Management Nurse/franchisees as first line managers In addition to nursing clinical skill, the new franchisee requires knowledge and skill in management (creating a team environment; setting employee goals, encouraging and disciplining staff, holding staff accountable to goals and standards of performance), accounting (summarizing the financial transactions and status of the franchise), marketing (communicating with customers/patients) and other “commercial” activities. At base, the management and accounting skills assume mathematical proficiency: the ability to do sums. . Among the nurse trainees there is a general lack of business understanding: money management, marketing, customer service, etc. and minimal understanding of legal obligations and consequences (taxes, cash management) Delayed Reimbursements Reimbursement has been slow because 1.) Home office OFH has had turnover in the financial accountant role (3 changes) in the past year delaying claims document production 2.) Mutuelle representatives in many locations also act as Community Center receptionists, checking patients in and out, handling the medical records and collecting fees. These competing tasks delay the claims processing. There is little or no incentive for the claims processing to be completed in a timely fashion. Note: Delayed claims processing is also a problem for other public health institutions and is not unique to the OFH Posts The Field Officer (FO) Role The FO is a critical role that was slow to arouse significant interest by applicants. New applicants have expressed interest in the requisite motorbiking skills and working outside of Kigali. The ideal FO has pharmacy or nursing background, ability to teach and communicate well; honest, organized, physically fit and able to ride a motorcycle, with interest in living in rural areas. Post Performance and Evaluation

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Electronic Monitoring The automated reporting systems require that franchisees gain a proficiency to exploit the full features and efficiencies of the system. In addition to a wide variance in the ease of using the technology, some users may not understand the range of purposes to which electronic monitoring can be used to spot problem, identify solutions and create inter-post compliance improvement strategies. Compliance and Assessment The compliance process is in its earliest phases of adoption so has few consequences when franchisees are out of compliance and lacks rigor as the same assessment from a previous assessment may be used in a follow-up. There is a lack of fidelity between the compliance site review and the Quality Service Checklists found in the Operations Manual. Self-grading is biased and incomparable between and among franchisees. PPP Collaboration and Local Expectations Challenge: Growth hampered by local health priorities, re-modeling requirements, expectations OFH would like to expand into selected areas, but must await a district invitation. Growth is dictated by the priority given health by the local communities and their District leadership. Once invited and a site selected, mobilizing the local administration to remodel the clinics can be slow to occur. In some areas the community partnership role has been misunderstood: communities were expecting nurses to rent the space (expected income) v. incurring a cost to provide the space. Challenge: Local bank loan financing The initial PPP plans include a partnership with Ecobank to would provide the loans through Ecobanks’ Corporate Social Responsibility department. As part of this agreement, nurses must have Ecobank personal or business accounts. Ecobank has few locations outside of Kigali which impedes access to loan capital for expansion. In some rural areas there is difficulty in finding a local bank of any kind. However, most of the administrative offices provide some government sponsored banking services. These branches do not accept checks, dealing in cash only. Therefore dispersing reimbursement money back to the nurses in these areas requires additional steps, exacerbating the delays in reimbursement. The Way Forward OFH has the challenge of scaling to full capacity by 2019 with ~500 operational posts while bringing all the posts into compliance and creating a culture of continuous improvement. As an IPIHD innovator it has the added challenge of developing evidence for performance improvement while moving along a developmental pathway to establish causal linkages and aspires to improve

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the health status of populations where the posts operate. These are formidable challenges that will require sustained and significant effort by franchisees and OFH leadership. OFH will also need continued support from the PPP partners, a stable government with continuing commitment to health goals, and technical support from IPIHD and other actors with specialized expertise. With the full support and collaboration of the MoH it suggests OFH has a greater potential of reaching full scale than other franchise drug shops innovations. And yet these same potentiators for success can create barriers. For example, MoH may be more sensitive to public scrutiny as regards OFH performance indicators and patient or community criticisms. Human resources for health is at a crisis level in many African countries including Rwanda. Recruiting, training and retaining nurse franchisees while quickly growing the number of posts is a significant challenge. Establishing and expanding the hub and spoke management structure while growing a reliable supply chain is a substantive enabling objective to support the expanding number of posts. OFH draws from its substantive experience with CFW in Kenya and its PPP partners. In addition, readers of this case can become involved directly with OFH and/or IPIHD in the following roles. Technical support for OFH management: OFH can benefit from the management experience of other “health posts” franchise models operating in peri-urban and rural circumstances. Others have experience in establishing supply chains and effective management models which quickly establish new outlets while achieving compliance and inter-post uniformity. Technical support for nurse/franchisees: OFH can benefit from the experience of seasoned local health franchise operators and trainers. First line nurse operators have operational, financial and clinical skills to quickly learn. Finding the right combination of performance metrics, motivation and training has no simple or single recipe. The experience of others to directly assist nurse franchisees is welcomed. Evidence and evaluation technical support: OFH can benefit from development organizations, non-governmental and governmental; public and private not-for-profit and for-profit expertise in evidence gathering. There is the technical operational challenge of efficiently collecting performance evidence while building upon the initial evidentiary basis toward evaluating individual and population health outcomes which result from OFH. OFH welcomes support as it moves along the evidence to evaluation continuum. Advice and counsel to PPP partners: PPP’s have grown in number and sophistication for health care in resource poor settings over the last two decades. A well functioning PPP acknowledges the divergent interests of each actor in the partnership. Others who have participated in such partnerships or advised their formation and maintenance can assist the PPP which links the public and private interests in Rwanda for OFH. Joining IPIHD: Several corporations and NGO’s are members of IPIHD. Their financial and intellectual contributions, along with their direct support to innovators, is the core strength of the international partnership. Interested parties can join IPIHD at differing levels of involvement and can selectively choose to work with a specific innovator such as OFH.

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IPIHD will continue to provide technical support to OFH and periodically update this case report. If resources and circumstances support it, IPIHD may write an update to this case study on the progress being made toward the scaling goals and development of evidence leading to evaluation. Ideally, a replication of OFH will occur in another region or country and can occasion an update on this innovative approach to providing first line care to patients in urban, peri-urban and rural areas. There is much that can be learned from OFH’s unique combination of features that aspires to benefit communities, patients, franchisee-nurses and realize Rwanda’s vision to create a coordinated first touch to the health care system through the network of OFH posts. Discussions Questions

1. How is OFH different than other rural drug shops franchise operations found in other low income or emerging market countries?

2. There are several challenges facing OFH (the following are not exhaustive): 1) maintaining

the good will and follow through among the public private partners, 2) establishing new shops, 3) gaining compliance and sustainability of existing shops, 4) working effectively with the Ministry of Health. If you were leading OFH what would be your priority order for focus and attention among these four challenges?

3. OFH is an innovator partner in the International Partnership for Innovative Healthcare

Delivery. Why would a innovator want to partner with IPIHD and what would they look for from that association?

4. How would you measure the success of OFH? What milestones for success would you

establish at the individual post level, at regional level and at the entire network/system level to show progress toward “success”? How would different stakeholders view “success” for OFH?

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i Business of Health in Africa 2006 IFC ii Innovative Models in Healthcare Delivery: Landscape Mapping WEF 2010 iii Bhattacharyya, Khor, McGahan, Dunne, Daar, Singer “Innovative Health service dlievery models in low and middle income countries - what can we learn from the private sector?” Health Research Poilcy and Systems, 2010 iv “Public Private Investment Partnerships”, The Global Health Group, UCSF 2009 v “Kenya: Private Health Sector Assessment” USAD 2009 see “improved policies for PPP” p. 57; need Rwanda reference on PPP’s vi ADDO/SEAM reference here vii Goodman C, Kachur SP, Abdulla S, Bloland P and Mills A. “Drug Shop Regulation and malaria treatment in Tanzania - who do shops break the rules, and does it matter?” Health Policy and Planning, July 2007 viii Goodman et al, “Drugs shops in Tanzania……” 2007 ix

Turning Vision 2020 Into Reality, From Recovery to Sustainable Development, National Human Development Project,

Rwanda, 2007. x Rwanda Vision 2020, http://www.minecofin.gov.rw/webfm_send/1700

xi Dorothy E Logie, Michael Rowson, Felix Ndagije “Innovations in Rwanda’s health system: looking to the future” The

Lancet; 372: 256-61, July 10, 2008. DOI: 10.1016/S0140-6736(08)60962-9 xii

CFW Shops, HBS Case, 2011 xiii Add HRH crisis citation here xiv

McKinsey, CFW Shops PowerPoint deck xv

OFH Ghana Proposal 11.26.2011 xvi

HBS Case, CFW Shops xvii

McKinsey, CFW Shops PowerPoint deck xviii http://www.who.int/mediacentre/factsheets/fs275/en/index.html xix http://www.balancedscorecard.org/