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Addressing SDG goals: Design thinking and working towards Universal Health Coverage (UHC) in Kenya

Last year, ThinkPlace had the privilege of speaking at The Future of Design Thinking event at d.school in Paris in front of an audience of over 600 people. The amphitheatre was full of optimism, energy and intrigue regarding the value of design thinking in society. To us, it is a perspective on the world that embraces ambiguity. It is a way of working that recognises that rarely do we know all the things we need to know to make perfect decisions. It is a culture of tolerating differing versions of the facts and not drawing conclusions too quickly. It allows us to navigate through complexity. At ThinkPlace, we apply design thinking to all sorts of complex public sector challenges. In this article, We will share an example of using design thinking to tackle two of the Sustainable Development Goals (SDGs), to strive for a reduction of poverty and to increase good health and wellbeing and how this brings Kenya closer to the goal of achieving Universal Health Coverage (UHC) for its citizens.

In Kenya, three quarters of the population are uninsured and must pay out-of-pocket for their health services. Kenya’s National Hospital Insurance Fund (NHIF) is the government provider of the social health insurance and has been assigned the task of achieving “universal health coverage” for all Kenyans. The political mandate means growing its membership from 2 million to 24 million in the next two years. NHIF membership is compulsory for all salaried employees. For the 80% of the country’s workers in the informal sector, membership is voluntary. This has resulted in coverage of the informal sector remaining considerably low. ThinkPlace worked with NHIF to find out why: why are people were not enrolling and why do they not stick around once they do? We spoke to 102 people in total, this included current, former and potential members as well as NHIF senior managers, branch level staff and accredited health care facilities. We learnt that there were many barriers that could affect someone’s willing participation in the scheme (see figure 1):

Figure 1: Barriers to uptake and retention of NHIF membership

People don’t experience a whole system. We experience a pathway through a system. That pathway is shaped by the numerous products, services and touchpoints that form that experience. For example, we met one lady in Kenya who went to the hospital for her sick son. The IT system showed that her NHIF mobile payments were not up to date, and despite showing them her payment receipts, she was turned away. She called the NHIF contact centre, where she was told to go to the head office which is a two hour commute away. When she got to the head office the next day, she lined up for another two hours, and finally spoke to someone behind the counter, only to be told she had to write a letter of complaint and to wait for a response in the mail. Meanwhile, she is forced to pay cash upfront for her son’s treatment. Now that is an example of a bad experience! Public system experiences are not like buying a book from Amazon or ordering take-away food: the stakes are a little higher. When a public system experience goes wrong, it can have real consequences for someone and their family, and it could mean a person choosing not to participate any further in something that would have benefited them or their community.

Many of the things we learned from such stories were the kind you cannot induct from traditional data collection methods. Instead, our insights came from taking the time to understand how users behave, what they believe, and how the culture and relationship dynamics have subtle but powerful effects on things like health seeking behaviour or payment compliance. If we didn’t talk to our users, we would have just ended up taking guesses. People’s stories were very powerful in helping senior managers and even branch managers put themselves in the shoes of their clients: the way we need to appeal to Teresa, who is able to pay but thinks the service is lousy, is very different to how we need to approach Samuel, who is not able to pay but is desperate to join the service. The NHIF senior managers told us how this helped them to get to know their members on a personal level and to see the 24 million members they were targeting as real people, with different needs and preferences. With this in mind, they could make better decisions for the community. We have a long way to go but reaching the SDG goals are within our reach, we just need the right thinking to get us there.