Jacaranda Health: Scaling high quality cost effective maternal and new born child health services in Kenya
By 2016 Jacaranda Health had established services for mothers and babies before, during and after childbirth that were recognised as providing a very high standard of care and among the best outcomes in Africa. It was providing these services in two for-profit healthcare facilities at affordable charges for lower income families but high enough to cover direct costs. Although Jacaranda was providing excellent quality and affordable care, the model of care was not easily scalable so the benefits went to only a small number of mothers and babies.
EfD initial support in 2016
EfD engaged in an extended discussion with Jacaranda about ways to scale up its model of care to generate comparable benefits for a much larger number of mothers and babies. After both parties realised that they did not have the answer, EfD agreed to provide funding to explore possible options. The initial focus had been on entering into management agreements with private and public sector providers with a view to Jacaranda taking on responsibility for implementing its model of care in their healthcare facilities. It always seemed likely that this approach would raise insuperable difficulties and so it turned out. The outcome was a complete revamping of the approach based on finding ways to extend Jacaranda’s high quality model of care to public sector healthcare providers.
EfD support in 2018
The revised strategy involves Jacaranda working with County governments (who run all of the public health facilities and services in Kenya) to use Jacaranda tools and protocols to upgrade the quality of care of maternity services in publicly-funded healthcare facilities. The key programmes are a midwife mentorship programme that upgrades provider capacity to handle basic and emergency obstetric care and client-focused, lightweight mobile phone tools that encourage pregnant women and new mothers to seek appropriate care before, during and after childbirth. After an initial proof-of-concept stage a full-scale proposal was developed by Jacaranda and discussed with EfD. The aim of the programme was to enable health workers in public health facilities to provide the same quality of care as Jacaranda’s to many more mothers and babies; and also to multiply the impact by bringing about policy change and strategic partnerships with more Counties and public hospitals. EfD agreed in Q3 2018 to fund part of the cost of the initiative. The proposal approved by EfD is set out in this document.
In 2019 and 2020 updates from Jacaranda indicate that the programme so far is proving successful. Jacaranda’s plan is to continue to scale up its approach to many more public facilities across 10 Counties, thereby improving quality of care for over 1 million mothers and babies. A summary version of the plan is set out in this document.
EfD Support in 2021 - 2022
Jacaranda Health & Enterprise for Development
End of Grant Report, Dec 2022
Summary of Grant
Jacaranda Health and Enterprise for Development (EfD) have had a long-standing partnership centered around the scaling of two core solutions to improve the quality of maternal and neonatal care in Kenya’s public health system. Since 2018, EfD have played a critical role in refining Jacaranda’s nonprofit business model and, more recently, supporting the organization’s operational path to scale - from expanding county government partnerships to unlocking government financial contributions towards programs for long-term sustainability.
From its onset, Jacaranda’s approach to improving MNH care quality has relied on local government partnerships to direct efforts in-county and provide the distribution network for its two core solutions; an AI-enabled digital health tool for PROMPTS and peer-to-peer nurse mentorship program MENTORS. The ‘Kenya County Expansion Initiative’, proposed in 2018 and running between 2019-2021, focused on validating and refining this approach at scale ahead of national and global expansion. EfD support helped test public-private partnerships to achieve, and sustain this impact at scale, including (1) ensuring the cost-effectiveness of solutions, and (2) unlocking government budget contributions.
Summary of Progress
Support from EfD and several other funders has helped chart a rapid growth trajectory for our solutions over the last three years. Importantly, this has also correlated with tangible outcomes for the 2+ million mothers and their babies we currently serve across Kenya and, more recently, Eswatini and Ghana.
Our progress over the grant period can be characterized by careful and committed engagement of governments as co-owners of solutions, rigorous qualitative research and human centered design to empower the end-user, and an incorporation of cutting-edge, locally-developed technology – led by our Kenyan team on the ground. The growth and diversification of certain internal teams - Partnerships, Product, Data, Research, Design and Evaluation - reflects our commitment in these areas. This progress and its core drivers is detailed below.
Expanding reach and impact across Kenya:
Over the last three years, we have charted a steep growth trajectory for our solutions. By 2021, our ambition was to have solutions deployed across 150+ public facilities and 10 counties, improving quality of care for 240,000 new and expecting mothers. By 2022, our core solutions have helped improve maternity and newborn care for over 2 million mothers across 1,100+ public health facilities in 20 counties in Kenya. We currently reach over 50% of pregnant mothers across the country, served by a cohort of 6,660 EmONC-trained frontline government maternity nurses.
The scale by which we’re able to meet the needs of 2 million women is realized through several front and back-end efforts to increase the accessibility, inclusiveness, and responsiveness of our platforms at scale.
Over the EfD grant period, we have:
- (i) Improved the efficiency of our PROMPTS helpdesk to support high-risk mothers. Upgrades to the helpdesk technology and an expanded team of agents have enabled faster response times for mothers. The helpdesk now manages ~5,000 incoming questions daily and high-risk flagged queries are responded to in <15 minutes (5 minutes for urgent cases). We have expanded our machine learning capacity to automate responses against a granular set of message categories, increasing the personalization/accuracy of responses and ensuring agents continue to refer priority cases at scale. 90% of high-risk moms now report receipt of care in a referral facility.
- (ii) Increased supervision of facilities to standardize routine EmONC training amongst providers and incentivize completion of Jacaranda's accredited MENTORS curriculum. Between 2019-2022, completion of essential modules increased by 40%, driven by efforts to prioritize support to poor performing, yet high-volume facilities and co-developing facility workplans to block routine times for training. Across this period, nurses in 339 facilities took part in 6,560+ theoretical trainings (CMEs) and applied this knowledge within 2,670+ simulation-based drills.
- (iii) Expanded our capacity to collect, analyze, and share actionable data from solutions. Extensive qualitative research with moms, nurses and county partners has helped optimize our data processes for data collection and analysis at scale. Over the grant period we;
- Used HCD approaches to test the credibility, content and sequencing of PROMPTS messages to incentivize greater engagement with mothers, improving engagement rates on certain revised message flows by 600%.
- Developed a set of fully-automated dashboards to increase visibility, analysis, and coordination around often-siloed client/facility challenges. These dashboards triangulate large sets of data from across Jacaranda’s solutions, and that of our key partners, to map priority government-identified MNH indicators (eg. infant immunization gaps, blood availability, emergency referral, and patient experience data).
- Conducted focus groups with facility and county representatives to understand priority indicators, gaps in health system visibility, and interpretable formats for data sharing.
This optimized model has already achieved tangible and dramatic outcomes; reducing maternal complications and decreasing neonatal mortality by as much as 25%, improving nursing skills, and measurably improving quality of care across public facilities. Our grant proposal set out several output and outcome targets in target facilities. Progress against these targets is outlined below:
- Improved health-seeking behaviors: PROMPTS empowers mothers with information, including advice, reminders, and milestone messages, to seek services linked with better outcomes. Over the grant period, we saw the following shifts in health seeking behaviors and knowledge amongst mothers using our PROMPTS platform;
- 87.17% women reported they had completed 4 or more prenatal (ANC) visits across PROMPTS partner countries, against a proposal target of 70%. PROMPTS follows-up with mothers after each visit to check that essential clinical steps were performed. Over the grant period, 540,000+ mothers provided feedback on the clinical quality of their last visit, helping identify gaps in service delivery during the critical prenatal period on a facility level.
- 71.1% of women reported that they had been asked to return for a postnatal visit by a healthcare provider and almost all (96.8%) honored this appointment.
- 84% of women reported that they had taken up postpartum family planning services by or before 8 weeks post-delivery, an increase on the proposal target of 77%. In Q3 of this year, Jacaranda prototyped new, family planning-specific PROMPTS messaging, with preliminary data showing promising evidence that the platform could be used to further incentivize uptake of family planning, return to fertility knowledge, and healthy birth spacing.
- 58% of women could name danger signs they may experience during pregnancy and after birth (30% improvement)
- 80% of women can name a danger sign they may see in their newborns.
- Improved EmONC skills and knowledge amongst frontline government nurses:
- Improvement in provider newborn resuscitation skills from baseline to 90%
- 98.11% of mothers surveyed on PROMPTS reported to have had a skilled birth attendant during delivery.
- Basic obstetric skills, observed through delivery debriefs, sustained at 90% levels for 6+ months.
This scale and impact has been made possible via our government partnerships which offer not only the distribution channel to deploy our solutions at scale across public facilities, but also the direction for how these solutions can directly address MNH priorities at county level. We predicted a total of 10 county partnerships by the end of 2021; by November 2022, we have doubled this, with current coverage across 20 of Kenya’s most populous counties, representing over 60% of the nation’s annual deliveries.
Securing long-term sustainability of our core programs:
During the grant period, we focused on laying robust foundations for transition of solutions to government partners. EfD funding not only helped unlock government financial contributions towards these programs, but also their adoption and endorsement as a standard of care in the public health system.
Increasing government financial commitments: Our proposal anticipated that other entities (including government and telecoms) would bear 90% of the program running costs for MENTORS by 2021. Our county partners are currently covering an average of 64% of the total program running costs, and have started to invest in PROMPTS too as a low-cost, high-impact way of reaching mothers with information at scale. In retrospect, as we have worked with the counties for the past few years, we think that 90% was too high a target - because we’ve realized there is a certain amount of costs associated with the program that Jacaranda will need to continue to bear. Our goal now over the coming years is 75%. Nevertheless, 64% is still a high number for government cost share and speaks to both how government partners value the program (that they are willing to allocate scarce resources to it), and the prospect of long term financial viability of the solutions, expediting their transition to government. This work included:
- Achieving low unit costs and economies of scale. During the grant period we reduced the cost per mother on PROMPTS to $0.74, in part due to a reduction in the cost of bulk SMS through close partnerships with local telecom Safaricom. MENTORS is currently ⅕ the cost of similar five-day classroom-based trainings in Kenya. During quarterly county progress meetings, the cost-effectiveness of MENTORS and strong evidence of programmatic impact has emerged as the principal reason for increasing levels of county investment. For example, in Kirinyaga, a county executive representative cited MENTORS as ‘the most affordable means of capacity building health care workers we’ve seen so far compared to other EmONC training packages.’
- Driving towards implementation-based county partnerships to increase financial and operational ownership of MENTORS. For example, in Nairobi, the County’s Reproductive Health Coordinators are co-implementing MENTORS in facilities, helping quantify our program data with firsthand experience. 82% of MENTORS running costs in Nairobi are now covered by NMS, the capital’s government body.
National-level endorsement for solutions: Over the grant period, the strong evidence of impact described on page 3 and deep insights we’ve generated through our data and dashboards, have positioned us as a key influencer over national best practices in MNH. In 2020, our MENTORS program was accredited by the Nursing Council of Kenya, and our curriculum has since helped shape Division of Family Health’s new National EmONC Mentorship Manual and training tools. In 2021, the Division of Family Health endorsed national scale-up of our PROMPTS and MENTORS programs, charting a path for their long-term sustainability and government ownership.