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1











One Family Health Rwanda:
Achievements and Challenges

2012


IPIHD
1

Case Study

#101


FOR DISCUSSION PURPOSES ONLY

NOT FOR DISTRIBUTION

draft


Liz Charles, Jeffrey Moe, Richard
Bartlett



NOTE: Students reading the

case for lecture by Jeffrey
Moe shou
ld 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 lead
ership in July 2012. A

desk audit
of materials provided by OFH before her onsite
engagement and her observations and int
erviews 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


2










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


M
inistry 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) p
osts 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 need
s (e.g. malaria, child dia
rrhea
) and relieve high
demand on community health centers.
The vision is to establish 500 posts by 2019 s
upported
through
a public private partnership (PPP) which includes

One Family Health (OFH) Foundation,
G
laxo
S
mith
K
line
, 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 increas
ing access to essential medici
nes 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 opera
te 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

healt
h insurance scheme, the
Mut
uelle 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 syst
em which allows the
3


Ministry of Health to monitor disease states of particular national interest (e.g. malaria) and areas
of national focus (Vision 2020 goals) which are related to Millenium Develo
pment 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

wh
ich 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

th
r
ough no
vel 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 fran
chising schemes.
Included in these new approac
hes 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 “
lev
erage private
sector expertise and investment to serve public policy goals
-

specifically the provision of high
quality,
affordable preventive and curat
ive care to all citizens.”
iv

While the long term nature of the
partnerships can strain the patience an
d 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.
F
ormal
pharmacies

are very limited in number in populati
on 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 c
oncerns among
observers regarding uneven quality of product and service offerings, poor training of franchise
owners, non
-
compliance with pharmaceutical regulations and overall
concern
t
hat 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
need
s 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
4


has proven to be

extraordinarily difficult

whatever the reform or
innovation
. For example, ADDO is
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 reac
h locations meets

two of the criteria: cost and ac
cess. 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 exacerbat
ed 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 f
ramework “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 Go
als 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 200
8
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 w
h
ere GNI was $48,100, life expectancy was 78
years, the chi
l
d mortality rate was 8 per 1,000, HIV
prevalence was 0.6% and 100% o
f 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


5




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 wor
ld.” 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 Store
s 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
clin
ics
operating as One Family Health (OFH) into the government’s
strategy in achieving their
Vision 2020 goals.


The
OFH p
osts 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;
allow
ing him/her

to earn a living while

in
creasing 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 work
er 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
V
ision 2020 goal, of ten medical doctors per 100,000.
1

Rwanda’s Human Resources f
or 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), nur
ses 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 governm
ent 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 t
o 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 ineffici
ency, 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
a
llowance 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



6


point for basic healthcare in local

communities.
The Ministry of Health

accept
s

National Health
Insurance claims (Mutelle)
made b
y 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 establ
ish 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 prov
ide £1.8

million

($2.8 mil
lion)

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 throu
gh 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 agre
ement, 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 f
amily 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 diag
nosis, 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 dr
ug 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 otherwi
se 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 identifie
d 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)



A1
卯浥⁰潳琠獥捯湤慲y
敤畣慴楯温

㐵4

A2
 hr敥⁹敡r猠獥捯湤慲a
敤畣慴楯温

6152

Grand Total

6629

Source: DHSST, Dec 2009

7


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 trai
ning, one day of technical and logistical training and three days
of nursing and compliance training from the corresponding managing director. F
ranchisees are
trained in record keeping, diagnosing target conditions and accurately prescribing medicines.
I
n
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 busi
ness 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:
A
pproved 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 o
bligation 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 gu
idelines, 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” healt
h
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 ther
eby
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
8


clinics usin
g 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 ot
her 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 us
e, 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 u
sing 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
feed
s

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, re
view 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 s
uch 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 newsle
tter 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
manag
ement (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 I
llnesses:

Malaria, diarrhea,

malnutrition and
bacterial infections,
upper re
spiratory
infections, skin disease,
accidents, hypertension,
eye infection, pregnancy
related conditions,

parasitic worms and

bone and joint disease.


Source: HBS CFW Shops Case,
2011


9



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 mor
e 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
p
osts because of the
additional compliance and regulatory burden. Only rapid screenings are performe
d (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 Manage
ment


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 cus
toms 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 unava
ilable 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 en
forcement agencies are weak. The prevalence of substandard and counterfeit
drugs is a public health concern resulting in treatment failures, increased resistance and death
xviii
.
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 need
ed.


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 th
e 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
10


franchisees’ orders, making sure the orders matc
h 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 orde
r 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 t
he electronic health record
are the costs
associated with each
patient
visit.
Clinic revenue is generated
t
hrough claims processing by

t
he National Hea
lth Insurance
system (Mutuelle
), which

boasts
coverage of over
9
0% 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 n
eeded
claims information and organizes it
by

clinic and cell
location
. Each

month,

the

claim
s, 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 d
istrict offices

by the
OFH

Posts


A
ccountant
.


Dis
trict administrators
further
distribute

the
claim
s

to the
appropriate sector where

Mutuelle represen
tatives
, in addition
to their full
-
time assignment,

review each visit for

accuracy of
enrollment, t
reatme
nt, and reimbursement prices
.
Disputations

(less than 5% of claims)

are directed to
the
OFH

A
ccountant,
who investigates
the challenged
claims with the
appropriate
nurse franchi
see 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 where
by the Mutuelle c
laims representatives can access
the needed informa
tion directly through the LifeQube system in
view
-
only mode.


National Health
Insurance


Instituted in 1999, Rwanda’s
community based insurance
program, the Mut
uelle
de Sante,
reaches nearly 9
0% 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
cit
izen 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 commit
tee. 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
a
dministrative costs represent
5

8% of the total revenue.
1

1

Tho
ugh 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/


11


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 t
o 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 fun
ding 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 pr
actice, 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 (o
r
“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 franchis
ee 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 assis
t 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 t
he 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
12


through the clinic toget
her, 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 compl
iance
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 h
ealth
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 cas
es will be directed to the
comprehensive clinics.


Rwanda is largely a “walking culture.” Outside the city center
s

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 acces
s the same he
alth 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 o
n 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 b
y 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 r
egulations 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 pla
ced in those locales.


13


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 offer
ing 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
en
couraging 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 t
o 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. Th
rough 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 s
ervice.
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

exp
ansion

of the
OFH

Shops into their area.
This
request follows the prioritization

of
healthcare

within the district and an associated

willing
ness

to
direct r
esources

to this aim. The district locates potential buildings

for use by the health post
.
Structure
s 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 st
erilize equipment.
Clean water access is also imp
ortant and at clinics where
this has been a

concern, OFH has helped create

storm water c
ollection 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 sev
eral pos
sible site locations, members of the management team visit

the
sites accompanied by a district representative
.
Determination of site sui
tability 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 selectio
n is also
inf
luenced by population catchment

(a minimum of 5,000)

and if a
competin
g NGO drug shop/clinic
is

operating in the same area.


Most sites
selected to date have not required significant upfitting and are
part
s

of existing

government offices or school buildings. Fo
r exampl
e following a recent exploratory

visit

to the
14


Eastern District
of

Gatsibo, 19 sit
es were visited:

ten
w
ere
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
o
fficially enters into a partner
ship 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.) u
sing local craftsman as able.


Community discussions are a reliable venue to receive feedback to OFH franchisees. Rwanda enjoys
a culture of candor and honest r
esponses 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
capture
s performance information using the LifeQube platform.

Once
on line, a “d
ashboard
” appears on s
creen which is a snapshot of

c
urrent 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 provi
ded, malaria medicines in stock
, etc.

The LifeQube system has the capability to
initiate an email to t
he franchisee and the OFH
management

team

if specified cri
tical levels are
reached: l
ow 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 Norto
n which h
as
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 ti
me. This
data and communication
infrastructure
weakness creates

a barrier to adopting the
monitoring system; te
mporary paper records maintains
a

psychological link to the paper
-
based tradition of medical record keeping
.



IPIHD and OFH have been collabor
ating 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).




15





16






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 sc
ale 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 re
pository 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.













17


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/evalua
tion 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 develo
pmental 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
innovat
ors. The nature of each innovation necessitates a unique approach to evidence and
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 s
atisfy 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
-
inter
est 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. T
he
se “iron triangle effects” suggest how
resulting
changes i
n the
health status of the
populations

served
, changes

in risk reduction and/or patient
satisfaction with
the services provided

occur
.
Inc
reasing 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 i
nformation with some likely
causal linkages
identified requires
years of effort and signi
ficant 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 ou
tcomes 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
-
supp
lying 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 t
heir pe
rformance 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 in
novative 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.






18


Human Capital/
Education and Training


Clinically, there is a wide variety of a
bilities 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 mini
mally proficient level in the 3 areas
irrespective of their capabilities at hire. Given a short training regimen it has been challenging to
teach necessary skills in short time. The difficulty of meeting the training commitment will be
exacerbated by tu
rn
-
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 discriminat
ing
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 shou
ld the content be a
nd if materials should be translated into
multiple languages (English, French, Kinyaarwanda)
. Beyond skills training there is a perceived
need to continue supporti
ng/encouraging entrerpreneurial
attitudes and collaboration. The
newsletters and continuin
g 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 sy
stematic
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 service
s


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 du
e 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 pres
ent cannot provide these maternal and child services per terms of the PPP.









19


Supply Chain Management


Challenges: Electronic Order and Re
-
Supply


The electronic process of stock ordering and delivery is time consuming for the manager.
Franchisees p
lace 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 woul
d be more
efficient if she placed orders for each clinic. However, this may distance the franchisee from
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 o
rdering, 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 practic
es and efficient
dissemination of supplies will become increasingly a challenge as the organization grows in size.


Staff a
nd 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 h
ad 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 rec
ords 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 institutio
ns and is
not unique to the
OFH

Posts





20


The Field Officer (FO) Role


The FO
is a critical role that was slow to arouse

s
ignificant interest by applicants. New applicants
have expressed interest in
the requisite mot
orbiking 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


Electronic Monito
ring


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 consequence
s 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 Operation
s 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 se
lected 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 b
e 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 location
s 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 br
anches do
21


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 improvemen
t
. As an
IPIHD innovator it has the added challenge of
developing evidence
for performance
improvement

while
moving al
ong a developm
ental pathway to establish causa
l linkages and aspires to

improve

the

health status of populations where the posts operate
.
These are formidable challenges that will
require susta
ined and significant effort by franchisees and OFH leadership
. OFH will

also

need
continued support from the PPP pa
rtners, 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 t
he
MoH it suggests OFH has a greater
potential of
reaching full scale than other franchise drug shops innovations. And yet these sa
me potentiators
for success can
create
barriers.


For example,
MoH may be more
sensitive
to public scrutiny

as regards
OFH
perf
ormance
indicators
and p
atient or community criticisms
.

Human resources for health is at a crisis level in many African
countries including Rwanda. Recruiting, training and retaining nurse franch
isees 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,
r
eaders 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, f
inancial and
clinical skills to quickly learn
. Finding the right combination of p
erformance metrics, motivation
and training has no simple

or single

recipe. The experience of others to directly assist nurse
franchisees is welcomed.


Evidence and e
valuation technical support:

OFH can benefit from development organizations, non
-
governm
ental 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
i
n resource poor settings over the last two decades. A well functioning PPP acknowledges the
22


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 o
f 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.


IPIHD will continue to provide technical support
to OFH and periodically updat
e 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 s
ystem through the network of OFH

posts.


Discussions Questions


1.

How is OFH different than other rural drug shops franchi
se 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 Innov
ative 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?













23





















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
Plannin
g, 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/