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Equal access to healthcare can be stilted in countries where private practitioners are a large proportion of primary health care providers. In a recent Research Article on Gates Open Research, coauthors Lauren Suchman, Edward Owino, and Dominic Montagu analyze one initiative designed to integrate private providers into government-supported payment schemes in Kenya. In this blog post, they share what this initiative looks like in practice and how such interventions can help integrate private providers into the social health insurance (SHI) fund.

The challenge of access to healthcare

Many low- or middle-income countries like Kenya are experiencing transitions in their health systems as they institute new policies and programs to achieve universal health coverage (UHC).

However, a constantly shifting political landscape can be very challenging for small private providers to navigate without a centralized institutional structure (like a franchisor) to support and represent them in their interactions with the government.

Private providers can join a few networks to gain more visibility and access to government financing mechanisms. However, these networks tend to be dominated by larger hospitals due to high membership fees.

This leaves small clinics to operate independently with little opportunity to interface with the government at all. As a result, government processes, such as new social health insurance (SHI) schemes, often seem mysterious and impenetrable to these providers.

The role intermediary organizations can play

The inspiration for our study came from an evaluation of the African Health Markets for Equity (AHME) program. The aim of AHME was to make quality private primary care accessible to people living in poverty in Kenya and Ghana. AHME supported quality improvement on the healthcare supply side (private providers) while also increasing affordability on the demand side (clients).

In both countries, AHME-supported providers were enrolled with a social franchise network. These social franchise networks provided resources for quality improvement. Additionally, the networks supported providers to become ’empaneled’ (or enrolled) with each country’s social health insurance scheme (the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya).

Simultaneously, AHME worked with the NHIS and NHIF to increase enrollment among poor populations. The goal was for NHI-enrolled clients to be able to access quality services at empaneled clinics for little or no cost. It became clear that franchise staff were doing a lot of work to facilitate empanelment among providers. Primarily by building relationships between the smaller private providers who make up much of the networks and the government.

We had data that smaller private providers often feel disconnected from government financing mechanisms and are intimidated by government processes. As such, examining these relationship-building activities seemed important.

The AHME interventions in practice

The AHME interventions aimed to deliver a package of interventions that:

• Improved provider quality (with a focus on small private providers)
• Supported private providers to run sustainable businesses
• Increased access to affordable quality care

This intervention package included franchising private providers with one of the AHME clinical service partners Marie Stopes Kenya (MSK) or Population Services Kenya (PS Kenya and offering them free access to the PharmAccess Foundation’s SafeCare quality improvement program. AHME also provided training and support for franchised providers to improve their business skills.

Additionally, providers received support to become empaneled with the NHIF in the form of franchise representatives who helped them complete paperwork and prepare for in-person assessments. The AHME program was completed in 2019.

Gathering the data

For this study, we drew from 126 semi-structured interviews with small private providers in Kenya. We interviewed providers about their experiences with the AHME interventions and their knowledge of the NHIF and experiences with the empanelment process.

Furthermore, we also conducted a parallel process evaluation for AHME. This included focus group discussions with representatives of each franchise who worked directly with the providers to assist them with empanelment and quality improvement.

In these discussions, we asked franchise representatives about their relationships with the providers and how they supported the empanelment process. We were able to bring these two datasets together for this analysis to give a sense of what these providers go through when trying to navigate complex governmental processes. We also captured how intermediaries like the franchise networks can help make these paths less intimidating.

Breaking bureaucratic barriers

We found that many providers were unclear on approaching the empanelment process. Others had started the process but faced roadblocks along the way. For example, long wait times, limited information, and absence of effective communication from NHIF.

As a result, the empanelment process felt opaque and intimidating. The AHME franchise representatives helped create and build links between private providers and the “street-level bureaucrats” at the NHIF. This increased information sharing through regular consultations between NHIF and private providers. Moreover, these connections led to increased confidence among private providers and an acceleration of the accreditation process.

Avenues for future research

Small private providers are integral to the health system and to achieving UHC in Kenya. These providers make healthcare more geographically accessible to populations that can’t be reached effectively by the public sector.

We hope that future research addresses the specific needs of these providers as they attempt to better integrate into the UHC efforts that may depend on them to be successful. In addition, we believe there is a need for funders to focus on supporting small private providers not only through program-directed work but through longer-term efforts that institutionalize their integration into the health system at large.

Read the full Research Article today on Gates Open Research.