Making health businesses healthier

Background
SEO and the African Population and Health Research Center (APHRC) evaluated the Healthy Business Development Programme (HBDP) in Kenya. This programme, led by the PharmAccess Foundation, supported small and medium-sized enterprises (SMEs) in the Kenyan private health sector between 2015 and 2020. The Dutch government supported the programme with a grant of EUR 1.8 million from its Facility for Sustainable Entrepreneurship and Food Security (FDOV), managed by the Netherlands Enterprise Agency (RVO). PharmAccess contracted SEO and APHRC to provide Monitoring & Evaluation support, evaluate the effectiveness of the various programme components and provide recommendations. 

The HBDP aimed to address three important ‘gaps’ that may constrain the development of SMEs in the Kenyan private health sector:

• Clinical gaps: Gaps in quality-of-care standards, procedures, or equipment, which undermine the quality of healthcare services and associated health outcomes. 
• Business gaps: Gaps in business management knowledge or skills that may prevent health professionals from efficiently running their health SME as a commercial business. 
• Finance gaps: Lack of sufficient financial resources, or limited access to financial products such as business loans, which constrain the ability of health SMEs to invest in expanding their business or address any of their business or clinical gaps.

Results
The evaluation team found evidence that the HBDP effectively reduced clinical, business, and financial gaps for Kenyan health SMEs. 

• First, the clinical support provided—in the form of SafeCare assessments and Quality Improvement Plans (QIP)—was generally well received by health SMEs. Interviews and survey results suggested that this often concretely helped health SMEs to reduce their clinical gaps, by improving their quality of care and encouraging them to invest in better medical equipment.  
• Second, the business development support provided was valued highly by recipients (notably by participants in the Managing Healthcare Businesses programme; a joint product of PharmAccess and the Strathmore Business School in Nairobi). Our survey among business school alumni, validated through follow-up interviews, suggested that the training contributed to improvements in business knowledge and practices (including e.g. their record-keeping, reporting, planning and budgeting skills).  
• Third, there was strong evidence that HBDP’s financial support provided through the Medical Credit Fund (term loans, cash advances, and guarantees) contributed to improving health SME’s access to finance without ‘crowding out’ financing from the financial sector. 

The evaluation team also found plausible evidence of useful synergies between the various types of support, owing to the HBDP’s ‘holistic’ approach. One strong aspect of the HBDP was that it provided its support only after an in-depth assessment of clinical and business gaps (the SafeCare assessment). Based on this gap analysis, the QIP subsequently provided concrete recommendations on how to address these gaps (with implementation progress monitored over time). Subsequently, both the clinical support and the business development support clearly helped health SMEs to improve their quality of care and business performance, which in turn helped improve their access to finance by reducing (actual and perceived) risks for banks.  

Methods  
This was a mixed-method evaluation, using a range of qualitative and quantitative methods. Using multiple methods and triangulating multiple information sources helped to minimise bias and to reduce the risk that the conclusions would not depend on a particular selection of interviewees. The key methods and sources included: 

• Desk review of programme and intervention documents, and other relevant literature.   
• Reconstruction of the Theory of Change for the HBDP.
  Descriptive analysis of the HBDP portfolio and the programme’s monitoring data (including on SafeCare outcomes and QIP progress).
• Collection and analysis of survey data (SEO and APHRC employed three different surveys) and external data on Kenya’s financial sector. 
• Semi-structured interviews with PharmAccess staff, health SME representatives, banks and financial sector experts, and both alumni and staff from the Strathmore Business School.
• In depth-assessment of a purposively selected sample of 8 Kenyan health SMEs. For these selected health SMEs, SEO and APHRC conducted in-depth, face-to-face interviews with various stakeholders on the full range of support received. In addition, the evaluation team collected business performance data (e.g. on patient numbers, revenues, etc.) for most of these health SMEs. Finally, SEO complemented and validated the case study results with survey and monitoring data.