Utilizing Technology to Transform Healthcare in Nairobi and its Environs
He wears several hats: from a humble background, he is the current Chairman of the Kenya Healthcare Federation (KHF), the voice of the private health players in Kenya and the Founder of Cresswave Limited, a company focusing on healthcare IT, a Medical Doctor by training, with a subsequent degree in Strategic Management. And most importantly, he is the Founder and CEO of Metropolitan Hospital. Meet Dr. Kanyenje Gakombe as he takes us through his journey of founding and running one of the leading private hospitals in Kenya.
When you first meet Dr. Gakombe, he strikes you as a no-nonsense fellow, but when you engage him, you meet this warm, well-versed person, with an inordinate sense of humor. We are at the Metropolitan Hospital in Buruburu estate in the east of Nairobi, under the warm mid-morning sun, and he is relaxed and ready to share with us his journey through transforming the health sector over the years. “I am all yours,” he says, as we sit down for an interview on the green, neat and well-tended lawns of the hospital.
After graduating with a Bachelor of Medicine and Bachelor of Surgery (MBChB) from the University of Nairobi in Kenya, Dr. Gakombe alongside other young doctors saw an opportunity beyond the overcrowded public healthcare facilities and a few private hospitals that were relied upon by millions of Kenyans to access healthcare: a middle class who could not access quality healthcare and could not afford healthcare in the existing private hospitals.
They then sat down and came up with a concept that would bridge the gap by taking care of this middle class and providing them with quality, effective healthcare. Buruburu estate then was the largest middle class single estate in the city of Nairobi and played a perfect location to this dream facility.
“There was the gap between the congested public sector and the expensive private sector, that’s the space we chose to sit in and that’s the space we are still occupying” he says.
That was 26 years ago in 1996 – and the rest is history – as the original idea of Metropolitan Hospital has since metamorphosed into providing healthcare services to not only the residents of Buruburu and those living in the eastlands area of Nairobi, but also to the surrounding counties beyond Nairobi.
Funding access challenges at the start
Dr. Gakombe and his partners faced a number of challenges, chief of which was the idea of starting a hospital as young graduates. He says that back then, unlike today, a lot of people had trouble with the youth, as they were not considered old enough to qualify to start and manage a hospital.
“We were not considered to be old enough to qualify to start and manage a hospital, that was one of the hurdles, too young”, he says.
He also says that he has grown to be very cooperative to the young future medical pioneers and he offers mentorship programmes at different levels to bridge this gap due to the challenges he and his colleagues faced as they sought to start the hospital. They were further dismissed by the Capital Markets Authority and the banks as they sought funding to start the hospital and later grow it. As a result, the team engaged older doctors who were passionate and more experienced to join their board, and give it more mass as they forged ahead.
He further adds that lack of capital was a major impediment at the start, as rates then were in the 30% range. Moreover, banks were not lending to the healthcare sector, as they considered healthcare a social enterprise and at the time private investors were very few.
Dr. Gakombe and the team later solved the above challenges by selling shares to the public. With a prospectus, they knocked on every door of relatives, friends and family members, selling shares to those who were interested in putting their money into the hospital, with many of the investors being healthcare professionals.
“The biggest investor was a British gentleman, the late Hancram Evans who believed in me as i had worked as his investment manager for 3 years during my internship”, he says.
He reveals that in the 1990s Kenyans had very little disposable income, so investors were asked to put in KSH. 10,000 as a minimum to buy 500 shares in the company, from which they raised KSH. 20 million and borrowed KSH 10 million from a local bank, then known as Daima Bank.
Dr. Gakombe shares humorously how much times have changed over the last 26 years. Today, he states that banks are willing to lend to the private healthcare sector and the society has accepted that it should be possible to have private for-profit hospitals.
“We have shifted from ownership of healthcare business being primary to the value proposition of the health facility”
Today, the focus is on what it costs to get a particular service provided and whether the quality is acceptable. There are more and more private for-profit providers, which is important since it contributes to the sub-sector growth. Take for instance the faith-based and the charity run organizations who are waiting upon donations to operate – donations can only go so far and is sometimes impactful in terms of sustainability.
“Government facilities with subsidized rates also depend a lot on taxes, looking at our tax revenues verses our 50 million population, there isn’t much per person per capita. This leaves the private for-profit subsector as the only sector which is likely to grow much faster as it can easily attract global capital. This also ties up with provision of quality healthcare due to healthy competition amongst various providers.”
Dr. Gakombe goes on to highlight that today there is private equity money, which wasn’t available back then, is available and more accessible, adding that back then foreigners were funding healthcare through the Ministry of Health while today they are willing to invest in private facilities directly.
He informs us that today the stock exchange is also more open to start ups and a company doesn’t need to have been profitable for five years to get a listing in stock exchange as per Kenya’s Capital Markets Authority.
He adds that by joining the Ibuka Programme, which was launched in late 2018 with the aim of preparing micro, small and medium-sized companies at the Nairobi Securities Exchange, Metropolitan Hospital has managed to attract financing for expansion, which they would not have been able to access before.
According to Dr. Gakombe, acceptance by the community and the patients around and beyond the neighborhood of Buruburu has been one of the many successes Metropolitan Hospital enjoys, as there has been a steady growth in the number of patients over the span of 26 years.
He reveals that the real breakthrough for the company came after the 2002 elections in Kenya, when the cost of money went down, the dollar stabilized, the economy was more liberalized, thereby enabling the hospital to import directly the materials needed.
Further, he reveals that the decision to computerize and digitize the hospital’s operations 1999 turned out to be a key game changer for the business, enabling it to turn around from a loss-making entity to register surplus from its operations. Through the use of data and automations, the vision of the hospital is to improve the patient experience as well as that of doctors, insurers and corporate partners amongst other stakeholders. This has been reflected in the initiatives championed by the hospital such as the recent initiative to share Covid-19 statistics with government facilities to drive efforts on improved vaccinations and reduce transmissions of the pandemic. Metropolitan Hospital was the only private hospital chosen by the National Hospital Insurance Fund (NHIF) the state parastatal offering medical cover to the public, as a pilot site for the new and upgraded e-claim system, and are currently working on an integration with the Ministry of Health for real-time transmission of medical data required by the government.
Serving the community beyond Nairobi
Located in the heart of Nairobi’s Eastlands area, Metropolitan Hospital serves not only the neighboring middle class population around it, but also attracts massive populations across Nairobi and its metropolis due to the quality and specialized care offered at the facility.
A level 5 facility, Metropolitan Hospital is one step away from being a Teaching and Referral Hospital as they are yet to teach and train doctors. The facility otherwise is a multispecialty hospital offering services across a number of specializations as well as training healthcare assistants across all cadres.
In 2013, the leadership started an aggressive expansion drive to grow the physical infrastructure and expand the scope to tertiary/specialized care and in 2017, the hospital attracted private equity funding that has enabled the hospital to grow and become the leading hospital in the eastern parts of Nairobi. This was done objectively to not only offer better and swift care to patients but also to stop the medical care traffic to India. Dr. Gakombe expresses with passion the need not to export dollars in the name of medical travel yet there are innumerable opportunities to be explored in the country. This upgrade also gave the highly specialized doctors who have worked with the hospital over the years a place to practice.
“It’s important that our own professionals provide the services and in turn gain the experience, to keep the healthcare professionals in the country. One of the key lessons learnt from COVID-19 is that healthcare by necessity has to be local. It’s impossible to fly a patient with a heart attack for instance, out of the country, thus the need to offer specialized care in the country and most importantly at the community level.”
With the upgrade, the facility is now well equipped to offer different services under the Outpatient, Inpatient and Specialist Clinics. The facility can conduct both open and non-invasive spinal surgery, which is not common in Kenya. Neurosurgery, Neonatal ICU, Orthopedics with specialization in ankle, knee and shoulder joints are some of the specialty services available at Metropolitan Hospital.
Some of the specialist clinics at the facility include, Gynecology, Family Planning, Nutrition, Ophthalmology, Endoscopy, Cardiothoracic, Medical Outpatient Clinic (MOPC), Dermatology, Urology, Oncology, General Surgery, Cardiology, Neurosurgery, Gastroenterology, Plastic Surgery, Mother & Child Health, Well Woman/Well Man, Pediatric, Surgical, Occupational Therapy, Antenatal Clinic, Comprehensive Care, Youth & Adolescent, Ear, Nose and Throat, Orthopedic Surgery, Physiotherapy, Midwife, Counseling Psychology and Psychiatry.
The hospital is now a 160-bed capacity facility, with over 350 staff, 400 visiting doctors and consultants, with an upgraded parking lot fitting 189 cars and 6 floor doctors plaza housing different specialties. It is accredited as a level 5 hospital in Kenya and has a Level F accreditation for its laboratory, both the among the highest level attainable by a hospital in Kenya. It has also installed a new Accidents and Emergency unit, Modular Operating theatres, as well as ultra-modern ICU and Maternity units. The hospital is also working towards a COHSASA accreditation by end of the year 2022.
“Today Metropolitan has a Class F laboratory, that’s the highest level of a laboratory you can have in a clinical setting, is a PCR testing center for travel, also still an isolation and treatment center in case of another wave. The facility is also much better equipped digitally to provide care through telemedicine and all the applications that came that allow digital communication.”
The COVID-19 pandemic opportunity
He describes COVID-19 during its first stages as the pandemic of fear, but which has enabled the hospital to build its capacity and skills in key areas of the facility. “Like most people, our first response to COVID-19 was to try and keep it at bay. However, we were lucky that our Chief Nurse had been part of the response team for Ebola in West Africa, which came in handy in building our capacity to respond to the pandemic in the early days of the pandemic”, he says. He continues to say that his staff were the hospital’s first priority to protect them from COVID 19. The facility therefore quickly trained its staff, acquired enough PPEs that enabled them pass through the first wave without any impact on its workforce.
The hospitals later acted as one of the main care facilities during the second wave of the pandemic, when the government facilities got overwhelmed and private facilities had to come through as care and isolation centers, converting one floor in the hospital building in to a large isolation and treatment center of 43 beds, with ICU and HDU capabilities – infrastructure that was not there before COVID-19, just like in most private hospitals in Kenya. By becoming an isolation and treatment Centre, the hospital later on through tele-training trained other practitioners on how to handle COVID-19.
“Then we came to the point where oxygen became the major problem – the facility installed an oxygen plant at the roof top to cater for oxygen needs and offered surplus to others. By the time the Omicron wave arrived, our ICU and HDU capacities were as twice as large as they were in the beginning, and the facility had digitized a lot more because contact was being limited. At the point when the COVID-19 vaccine came through in early 2021, our hospital became one of the first vaccine centers and later on a travel and testing center.”
He advises that the evolution of the COVID-19 pandemic was a demonstration of the fact that no one player can afford to cater for the needs of everyone in the country – neither the private nor public sector. Globally, there was also the demonstration that no one country is wealthy and equipped enough to deal with its population if a significant number of people fall sick at the same time, he adds. “We not only needed the health sector but the whole country, the citizens, the army, the agriculture sector and everybody else to participate when a pandemic like the COVID-19 pandemic hits.”
A more digital future
Metropolitan Hospital continues working towards its vision of becoming a one-stop shop for health and medical requirements by offering end-to-end services in a highly digitized environment. It is also striving to better its offering of quality, cost-effective and affordable health care services with the goal of becoming the leading hospital in Nairobi and across Kenya.
“We want the patient to be their own doctor, we want to enable patients to take care of themselves, or their caregivers to take care of them right at home by providing technological support. Metropolitan Hospital is a means to an end, it was never an end in itself,” he asserts.
At a personal level, his dream has always been on mentorship, thus his first focus is on mentoring the next generation of healthcare leaders in Kenya and beyond. At the corporate level, initially the hospital had a vision of being present in every province in Kenya, as they were referred to back then, a vision that was derailed by cost of money and the lack of capacity to expand.
The facility in future will pursue the hub and spoke model, where the main facility in Buruburu gets equipped and thereafter duplicated in different regions across the country. With the availability of human capacity at their disposal, the hospital is looking for partners and investors to expand its multispecialty hospital model with new facilities in key locations across the country.
Dr. Gakombe reveals that the hospital’s key area of specialty going into the future will be on improving care to those with long term illnesses. “Too often patients who are diagnosed with, for example, Hyper-tension
and fail to follow up on medication, later on come back to the hospital with a stroke; another diagnosed with diabetes and after a while comes back with kidney failure – all because of poor care of the first illness which escalates to a more dangerous condition. With the current digital capabilities, Metropolitan Hospital can track care right from digital monitoring tools at home, to the ICU. These people who have long term diseases can be kept healthy and productive in the community, as opposed to spending money in a hospital.”
He describes the future of healthcare to be just like the banking and financial sector. “We want the patient to be their own doctor, we want to enable patients to take care of themselves or their caregivers to take care of them right at home by providing technological support.”
The intention of the hospital from the beginning has been to raise the quality of care by providing essential care and more importantly by influencing the quality of care provided by the country. The hospital founders were cognizant of the fact that not all Kenyans would fit in its facility and as such Metropolitan Hospital is just a part of the whole healthcare system in Kenya that needs to be managed to have greater impact on people’s lives and the nation’s economy.
Despite Metropolitan Hospital being a private hospital, Dr. Gakombe is very keen on what happens to public healthcare since it is the first foundation to care in Kenya. He believes that engaging with the county and national government to raise the competitive bar of care across the county is key to improving care. He gives the example of the competition in schools in the education sector, and this he recalls with nostalgia.
“While at Mangu High School, our natural competitor was Alliance Boys High School, so every day we were worried about what they were doing and our teachers didn’t spend a lot of time convincing us to study: they just needed to remind us the competitor was studying. If healthcare is run like education, then we will raise the bar and even patients will know how to compare and choose wisely which hospital to go to for certain procedures and what results to expect.”
It is important that our own professionals provide the services and in turn gain the experience, to keep the healthcare professionals in the country.
Dr. K.K Gakombe – CEO & Founder , Metropolitan Hospital
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Leading the private sector to higher impact
Dr. Gakombe is an outspoken voice about the importance of a vibrant and sustainable private health sector in Kenya and the region – a trait he connects to his early schooling days at Mang’u High School and at the University of Nairobi, where he says he was taught and shaped to be a thinker and a responsible citizen who must be able to stand for what he believes in, and be willing to articulate it to everyone, including to higher authorities, at all times.
Besides being involved in advocating for health to be prioritized as part of the Big 4 Agenda, he was also instrumental in the initiation and development of the Standard Service Agreement and Claim Form between Association of Kenya Insurers and Kenya Association of Hospitals which was adopted in October 2006. He is passionate about the enabling role of ICT in health and has been instrumental in the design and development of Hospital Information Management Software (HIMS 2000) currently in use in several hospitals and E-care, the first digital catering platform in a hospital.
His recent elevation to chair the Kenya Healthcare Federation after a number of years on the Board, has given him the platform to continue with his passion for the healthcare sector in the country.
“Private for-profit healthcare facilities take a beating in the market for allegedly profiting from people’s illness and that’s why it’s very important that we focus on value. The ownership of the healthcare infrastructure should not be the key subject: it is the users of the service, whether it’s companies, individuals, or the government buying healthcare. Given the right quality, how much does the right service cost? This way there is more value and accountability from the tax money because we will be paying not for the inputs but for the outputs when the service is provided, as opposed to where we give money with the hope that services will be provided.”
He echoes his desire to see more accessible, equitable and affordable healthcare systems in Kenya, and where the public, private and faith-based organizations contribute side by side, with the consumer given more choice and experience. He adds that the achievement of Universal Healthcare (UHC) in Kenya will be grim if digitization and automation are not embraced across the health value chain, with the use of paperwork and manual forms still rampant across the country.
He gives an example of the insurance claims process. “In the case of managing insurance claims, if each of the 40 million plus Kenyan adult population make approximately 4 visits to a healthcare facility per year, this is a total of 200 million paperwork claims that need people to go through and subsequently pay. This is in itself a bigger barrier to attaining UHC that leaves us with just one solution: embracing technology and digitally integrating the entire health sector value chain to better services.”
“Healthcare is labor intensive since a lot of the cost is driven by what the healthcare workers earn. Healthcare is also highly specialized as the care givers are well trained and highly specialized persons. Many inputs used to offer care like the equipment in Kenya are mainly imported, as well. There are various opportunities for cost savings and one of those is task shifting, with technology support we can decide that these tasks are very patient centered approach to care and not provider centered. If patients can self-register, then we provide tools so that they self-register, you don’t have to pay anyone for doing the registration.”
“Taking a look at the financing side, can NHIF do it alone or do we need multiple approaches for financing?
And if you look at COVID-19 pandemic again, it taught us that even NHIF was not strong enough financially to pay for COVID-19 care, as this was excluded by NHIF. There is what NHIF can do, there is what private insurers can do and there is what the state will have to do.”
Dr. Gakombe contends that there is need to come together and address the finance and the human resource pillars of the health sector, and by doing so address the supply chain and the technological access issues, and thus build a more resilient health sector. And if the regulation side is also better, then all the players within the health sector will do their bit and contribute to a better healthcare system in the country, he emphasizes.
He further adds that devolution offers an opportunity to vastly improve healthcare services across Kenya in several ways. “The public will start comparing the level of care in different counties and our leaders will be forced to benchmark in successful counties, as they will be losing money when their people start travelling to other counties to seek care. That benchmarking will mean that our leaders will be under pressure to improve the quality of care and because healthcare is the most devolved function, devolution offers an opportunity for intercounty benchmarking and therefore raise the bar. It’s therefore important to work with the counties and the national governments to ensure that healthcare structures in the country is such that it encourages all players to be patient centered, in trying to achieve access and better cost outcomes and more fundamentally better clinical outcomes.”
Dr. Gakombe is fully aware that the only way to truly influence the world, is not just by a country’s doing but through knowledge. The ultimate influence across generations comes from sharing knowledge and ideas, not by having the largest pot of money legally or illegally acquired, he says.
This feature appeared in the June 2022 issue of Healthcare Middle East & Africa. You can read this and the entire magazine HERE
