Q&A with Access Afya: Evolutions in Primary Care

Access Afya is a primary healthcare social enterprise operating two kiosk clinics in Nairobi’s informal settlements . These clinics sell health services, diagnostics, products, and medication to low-income Kenyans. Through a continuously evolving design, Access Afya uses training, operational processes, technology systems, and patient care methods to ensure that low-income patients receive a higher quality of care. This approach to primary care for the poor shaped Access Afya’s participation in the Primary Care Learning Collaborative in 2013 and 2014. In April, CHMI checked in with the Access Afya team to learn how the collaborative has affected their work and to hear the details of their upcoming participation in the CHMI Learning Exchange.

1. RN: Access Afya was one of five primary care chains to participate in CHMI’s Primary Care Learning Collaborative last year and participate in the co-production of the new Innovator’s Handbook. Looking back on your experiences as part of the collaborative, what of learnings have you implemented into the Access Afya model as a result?

MM: That’s a difficult question! The collaborative was for a full year, so we made a lot of changes. We kept monthly reports during the program to track all the changes we were experimenting with throughout the year.

We talked a lot during the collaborative about being the first access point—that’s the origin of the word primary. Different countries, and different organizations serving different markets, define primary care completely differently, which was interesting. One of the biggest changes in how we conceptualized primary care services was dental—Ross Clinics in India offered dental services. I never would have thought of that—it’s not common in Kenya. We are now piloting dental offerings through a partnership model to understand the potential demand in our market. This wasn’t an instant investment; it was more of a re-conception of what dental services and primary care can look like.

Each model also has different strengths. One thing Penda is really strong on is the patient experience. That was something we always talked about during hiring—who is friendly, who is aligned with our vision—but Penda actually has a manual and had defined what the patient experience is for them. This motivated us to create materials defining our approach to positive patient experience, and use these in training and communication with our team members.

The collaborative was also about sharing. Lifenet shared their quality indicators with us and we incorporated some of these into our own quality monitoring indicators. The collaborative was really about a lot of sustained relationships and a willingness to share. By meeting face to face, we established trust and understood each other’s models, and could then go deeper on the monthly calls. For example, we could have a long call with Ross Clinics on supply chain management, and ask technical and personal questions.

2. RN: Access Afya currently has two clinics with plans to continue growing. Building on the success of the model so far, what are your goals for scaling in the next two years?

MM: Over the next two years, we are really looking at our solid build stage. We want to prove the programs we are currently running have traction and are replicable, so that at the end of two years we can move into our scale stage. We are looking at opening six more clinics in two years to become an eight clinic chain. With this growth, it is crucial that we continue to measure how the model may change with each new facility, for example, which marketing strategies are effective, and what the footfall and revenue is for each clinic. We need to ask ourselves—are our assumptions accurate and replicable?

We will be very focused on expanding our field-based care programs in the next two years. We will expand our Healthy Schools program from a couple hundred children to a couple thousand. In parallel, we will be building Healthy Employers and Healthy Savers programs using a similar operational model for field care.

And we need to keep looking at strategic partnerships—who can we collaborate with? Are there retail groups we could partner with on clinic build builds, for example, or school groups that we could use to sign multiple schools at once into our Healthy Schools program?

Continuing to progress on our technology roadmap is another focus for us. We have developed custom software to manage patient information, and in the next two years we will get this working seamlessly in field and facility based settings. Finally, we need to build up management team and start to specialize our staffs' roles to support growth.

3. RN: Turning to new activities on the horizon, Access Afya just won a CHMI Learning Exchange grant to work with Care2Communities on marketing pilots. What is your relationship with your Learning Exchange partner, and how did you choose to work with each other?

MM: I first met Care2Communities at SOCAP and found we had so much in common. So many commonalities of things we had tried, or had considered and didn’t try. So many similarities from how we thoughts about primary care all the way down to the details of our pricing and profitability. Jessica (of Care2Communtiies) and I have talked a lot about marketing and converting educational health outreach into sales strategies. We had started the conversation, but there wasn’t a structure for more collaboration even though we needed it. So when we heard about the Learning Exchange, it was perfect because it created that structure and a way to focus in on one question—how do you market to different customer and audience segments?—and it gave us some funding to really explore that issue.

4. RN: Access Afya has interacted a lot with CHMI over the years. What do you think the role or benefit of CHMI has been to you and Access Afya?

MM: The biggest moment for me personally was seeing clinics in India during a collaborative meeting—that was phenomenal and a whole new context to observe clinical and primary care. To see another developing world context that is so different than East Africa was interesting because it was not “home” and not familiar, which can make it more natural to observe every small detail. Ross Clinics (a member of the collaborative and where the site visit was in India) has more clinic sites than us, but it is still struggling with the same nitty-gritty details like the scheduling and cancelling of appointments. How long do you wait for no-shows? How far ahead should people be required to cancel appointments? It really drove home that people face common challenges in this field.

CHMI also allowed me to take a clinical officer with me to India. He had started a career with us about a year prior to the trip, and had never left Kenya. Working in this context in a social enterprise can be hard, but at the same time it was important to go together to India and to see the bigger picture behind this type of work. And for me to be able to do that for my team was really important. There are a lot of networks out there for innovators, but CHMI has a human interaction element. CHMI staff contacted me and talked to me about the program, its focus and its goal—and then it instantly made sense to me.

But why is CHMI great overall? CHMI is platform with real people behind it. It is not just digital—the database is great and you use it sometimes, but you almost forget it’s there because there is a staff behind it that genuinely cares about innovations. Whether it’s the policy side, the social enterprise side, the NGO side, the team is just really great and dedicated and caring. We can always reach out to them, and they really want primary care to succeed. That is different than the other groups we have been a part of—when I email the CHMI team, they always write back. And it’s been an ongoing conversation for three years now.

This interview was conducted on April 22, 2015 at the Access Afya offices in Nairobi, Kenya. To learn more about Access Afya and the primary care collaborative, see the Innovator’s Handbook and get in touch at chmi@r4d.org.