Preamble
The roll out of the Social Health Authority (SHA) platform has been messy. This is because of poor change management but mainly due to a serious trust deficit.
But SHA is a cog in a bigger wheel of Universal Health Coverage via health digitization.
Trust Deficit impeding health digitization
We as a country need therapy. We have not recovered from broken political promises. The trust deficit grows higher every day and every time a politician stands to speak. Politicians need to allow Ministry Of Health to run healthcare policy matters. People have massive distrust with the politicians we should now disentangle medical care from the politicians. It is important to disentangle politicians from healthcare because the health financing journey has been on for the past17 years. The health digitization journey has been on for the past 20 years with policy documents having been developed over time. This process and was independent of politics. The foundation of healthcare financing and digitization was good. It is important to have policies on health financing and digitization to protect the country from vendors who have to follow the Kenyan policy should they engage. For us to fix the social ill of poor healthcare financing and delivery the government should first build trust by doing fulfilling their promises to the citizenry and giving credible explanations when they fail to deliver on their promises. In healthcare they should keep off operationalization of health policies.
Digitization in Murang’a County, a case study in devolution
Murang’a County has digitized, not only health services, but other services like collection of county government incomes and fleet management. Hon. Irungu Kang’ata has attributed the increase in own source revenue of the county partly to digitization. Dr Gakombe, one of the advisors of the governor is a huge believer in digitization. I have used the digital health system at Kigumo SubCounty Hospital and I’m loving it.
Murang’a County health personnel have used the digital health platform for about one and a half years now and despite some of the challenges they would have difficulties returning to the paper-based systems. Health personnel have credentials to the health system allowing them to perform their specific purposes. In Murang’a County ward rounds and medical clinics are input directly into gadgets. Prescriptions are done online, and it is possible to view incomes of the day as they occur in the dashboard. Murang’a County is thus a county where digital health has successfully taken root where all other counties can benchmark on and adopt. I foresee the governor of Murang’a winning many awards in the future.
Health digitization, Good or bad – A View from Ryan Nyotu
Is health digitization of the Kenyan healthcare a good thing or a bad thing. Different people will view it differently based on their circumstances. I have had lengthy discussions with friends and colleagues on this matter. Different people have different interpretations of health digitization. I sort Ryan to get a deeper understanding of digital healthcare in Kenya. Ryan was the first Director for digital health at MOH and the immediate Past ICT Convenor KMA. I have hosted him on the #OneHealthLensPodcast Find the interview on https://youtu.be/RmOYCZJLxus?si=6Ootwmq8doY4SRUy
Why do we need to digitize healthcare?
Ryan opines that Universal Health Coverage (UHC) is the big picture. It is the Ikigai of digitization of healthcare. Kenya has tried UHC once or twice. A critical success factor identified towards UHC is data movement. For proper health financing visibility of utilization of the resources is key. For instance, if administrative costs are to be capped at 5% there must be a way of verifying this.
For medical business to thrive, submitted claims should be visible and must be paid for on time. Visibility of the medical commodities as they move around in the sector would ensure commodity security, in the quantities that they are needed and at the right time.
To appropriately argue for increased human resources for health, digitization can produce evidence supporting this.
How will health be digitized?
Kenya has had digital systems for a very long time that have been very siloed and fragmented. A lot of data is generated, but that data was not collated well enough to allow for the UHC aspirations to be achieved. Ryan thinks that this can be solved by implementing the Kenya Digital Health Superhighway.
What is the Kenya Digital Health Superhighway?
It is an ecosystem approach to digitizing healthcare. It’s foundation is in law, cyber security, connectivity, and governance.
The main thing in governance is a body dedicated to ensuring that there is a digital system, that standards are there, that data is always in the correct quality, to protect the citizens’ data. For a digital superhighway to work, ownership of data must go to end user who is able to have control over it. Patient data portability is another desirable attribute.
The Digital Health Act sets the regulations and laws that protect the rights of the data user in the sector and sets standards. It acts to protect the data integrity of people’s data in concert with The Health Act 2017, Data Protection Act and the Computer and Cyber Crimes Act. These act together.
At the next level all these facilities to be connected to the internet. You cannot remove paper from a facility, and then introduce a digital system, and then not cater for the internet costs of that facility. It is envisaged that some Facility Improvement Fund (FIF) monies will be set aside to cater for internet.
A robust cyber security setup is needed to monitor and protect health data. Outages should be anticipated and prepared for. Facilities will have backup.
Operationalization of KDHS
All systems must be made to speak the same language via implementation of the Health Information Exchange (HIE). The HIE is has an Interoperability layer, where once information passes there, it is converted to a standardized format i.e. when my system is pushing data to that interoperability layer, all systems from the community to the highest-level hospitals should transmit it in the same format.
HIE registries
HIE registries include Client Registry, The Facility Registry, The Healthcare worker Registry, The Terminology Service, The Community unit Registry and The Shared Health records.
The Client Registry allows the client to be uniquely identified. The number of facility-based identifiers disappears.
The Facility Registry allows a facility to be uniquely identified by code and the service they are allowed to do as per KMPDC or KMFL. This knocks out all fake facilities fake claiming
The Healthcare Worker Registry that controls who offers services according to the policies of the land. To date we do not have unique identification of health workers. We have unique IDs for doctors, unique IDs for nurses, unique IDs for other people but all of us as health workers we do not have something that uniquely identifies you.
The Terminology service determines what the language is.
Shared health records is where everything is written. It is the source of truth. So, if there is a dispute between claims or anything, the shared health records is immutable.
Case Uses for HIE
On this basis the first three case uses for the HIE can be deployed.
1. Social Health Authority system to allow claims to be picked directly from the facility, verified against the registries that all the data there is correct, returning to SHA, going through the automatic rules and processes according to the benefits, goes directly to the ERP and goes out. That process is meant to have as little as possible human interactions in the claim journey, to try and reduce the time it takes to verify and to offer a service and pay a claim.
South Korea implemented a use scale for social justice with a SHA vs HIE. Turnover time for claims is ridiculously fast like 3 days which means that the healthcare business becomes a true business. That will be the first pulse for quality to see if you push more money back fast enough are we able to improve the quality of service offered at facility level. This is in addition to all the funding. The SHA system is meant to increase transparency, reduce dependency on human beings knowing each other and make money move as fast as possible within the sector so that it grows.
2. Commodity Security
This is a Track and Trace system. It allows us to identify a molecule from the tie it enters the country from the manufacturer all the way to the time it is given to the patient. If the patient has a reaction, we should be able to know this drug came from this manufacturer and this should be something that can be done on the system.
So this is a massive endevour to digitize facilities. As facilities are being digitized EMRs must have an ERP for tracking commodities. The commodities will be uniquely identified, and they will be trackable across the system. This will allow us to know why drugs vary in price, why the same drug from the same manufacturer can vary in price. It can allow us to do things like pooled procurement.
3. Data Analytics
We are used to to DHIS 2 where we have aggregated data utilized monthly. The new system is supposed to help the country move to patient level data handling and analyisis. It is a huge task. Data must be anonymized to protect it.The insights are very good. Analysis at community level is already bearing fruits as small outbreaks are being identified very fast.
4. Digitizing community health and facilities.
Once the health digital ecosystem is operational, it should sustain itself and ensure that there will always be money in the sector, there will always commodities at the correct time, it should decongest facilities, and it should spur investment in facilities that will increase quality.
After 2-3 years of the system running then now you implement the quality-of-care bill. If you implement the quality-of-care bill right now you will get frustrated with counties.
On whether we should improve health services first before digitization, Ryan opines that there are two options in that chicken and egg scenario. We can wait until the system improves and then we digitize, or we can digitize to improve the system. He chooses to digitize the health system but depoliticize the process.