Digital Health and Entrepreneurship in Primary Health Care Settings – Kenya's Experience

Background: The limited number of sonographers in developing countries and high cost of conventional obstetric ultrasound screening services in high level facilities led to only 6.9% of pregnant women accessing the service in rural areas. However, Point of Care Ultrasound (POCUS) services in Primary Health Care (PHC) settings has shown the potential to enable developing countries implement the WHO requirement of pregnant women accessing obstetric ultrasound screening before 24 weeks gestation. Through POCUS, life threatening complications can be easily identified and managed on time thus reversing the Maternal Mortality trends in developing countries. Given the ease to learn and use POCUS technology, there is an opportunity to train selected PHC health professionals to offer the service at an affordable cost that supports routine acquisition of essential ultrasound screening supplies and entrepreneurial incentivisation of the care providers. The aim of this paper is to document viability of POCUS in a PHC setting of a developing country.Methods: One year post intervention, an evaluation survey got conducted in the project sites that spanned across two pilot counties in Kenya (Kajiado and Kisii) on viability of the entrepreneur driven implementation of POCUS services. The sample size was calculated using the formula to estimate the difference in proportions between two independent populations and sampling was done using two stage cluster sampling method. The survey adopted mixed methods in data collection. A sample of 33 Midwives who had been trained to offer the service and 196 women from Community Health Units (CHUs) surrounding the pilot health facilities took part in the study. Facility record reviews on the project also provided additional sources of information.Findings: Despite the COVID-19 pandemic that limited pregnant women’s utilization of ANC services, the trained midwives had screened a total of 1250 pregnant women in one year at a fee of USD 5 for each scan. 168 (85.7%) of the women confirmed the service was affordable and easily accessible in the local facilities. 85 (43.4%) of the women confirmed they were screened by midwives in local public primary health care facility and 28 (84.8%) of the midwives reported to have had sustainable acquisition of essential supplies needed for the service in addition to the performance-based incentive/token received from the intervention. Notably, 180 (91%) of the women interviewed recommended scaling up of the service. On effectiveness of the POCUS training, 32 (96%) of the midwives reported that the continuous mentorship and coaching by TOTs (radiographers) post the electronic and face to face training enhanced acquisition of knowledge and skills for the project.Although the project realised a marginal negative net present value of cash flows, the impact generated was of high significance. The project was viable from implementation perspective since it demonstrated the potential to reach a Break Even Point (BEP) at a modest of 1833 scans per year. The project has potential for further buy-in by Primary health care professionals having accorded them a gross margin of 60% with a probable increase to 80% in subsequent years.Conclusion: Obstetric Ultrasound screening services can be provided at lower levels of health system 1,2,3 by nurses and midwives among other PHC health professionals who are well trained. The POCUS services can be offered at an affordable and cost to keep the service delivery