Co-creating Innovation Investment Cases to support the scale up of health innovation through the public sector in Kenya
This blog is part of a series developed by Results for Development sharing learning from the design and implementation of a locally-led and demand-driven Public Sector Scaling Action Lab for East Africa. We welcome comments and insights from others working to scale up innovations within government health systems.
“Everyone wants to hand over innovations to government.”
On the surface, this observation from Dr Salim Hussein (right), Head of the Department of Primary Health Care within the Kenyan Ministry of Health, sounds positive, and yet it was actually the first in a long list of challenges hindering public sector scaling of innovation that he shared in opening our recent workshop in Nairobi. Other problems in his list included a lack of meaningful government engagement by innovators and development partners primarily concerned with pushing their own solutions and agendas; a lack of sufficient evidence to inform effective decision making around the solutions available; poor planning and management to support the integration of those solutions within the health system; and a lack of appropriate monitoring, evaluation and adaptive learning to understand how well those innovations were operating once adopted.
None of the other government participants gathered in the room - who represented senior leaders and technical staff from the national Ministry of Health, the Council of Governors and the County Executive Committees from Makueni, Kajiado, Kisumu and Trans Nzoia counties - appeared particularly surprised by these challenges. Nor did the innovators (from Sanivation and Vaccibox), the investors (Villgro Capital) or the ecosystem facilitators (from the Kenya National Innovation Agency, KeNIA). In fact, it was the recognition of these challenges and agreement with Dr Salim’s observation that “we cannot deliver the best healthcare to all Kenyans without investing in innovation” that had no doubt prompted such expansive participation in this workshop, and that underpinned the uniquely honest and open discussion that characterized discussions throughout the day.
Organized by Results for Development (R4D) and expertly facilitated by three Kenyan-based ‘Champions’ from the Public Sector Scaling Action Lab made possible with the support of Grand Challenges Canada and Global Affairs Canada, this workshop was convened to explore a new approach to addressing some of these persistent barriers. Building on the six-stage “Mountain Model” framework emerging from in-depth consultation with a range of public and private actors in Kenya, this workshop aimed to test the appetite for ‘Innovation Investment Cases’ (IICs) - a tool that enables governments and innovators to collaboratively design an evidence-based argument for attracting the additional support (financial and non-financial) required to help governments scale-up innovations that align with their need / demand (see this blog for more on the rationale for innovation investment cases).
Before getting into the detail of the IIC template, participants took time to listen to the experiences and insights of senior health officials from county governments in Makueni and Kajiado, who with the support of Insight Health Advisors had used the Mountain Model approach to identify priority areas of demand and select two matching innovations (Vaccibox and Sanivation respectively) through a comprehensive sourcing and assessment process. Having a flexible structure such as the Mountain Model to follow had clearly proven very beneficial for both counties - as Dr Joseph Kanyange (Makueni County Director, Health Products and Technologies) remarked, “Before the Mountain Model, we had no clear process for handling all of the innovations being presented to us, and we were losing opportunities as a result”. Similarly, Samson Saigilu (Kajiado County Director, Public Health and Sanitation) noted that “we’ve always had health priorities, but struggled to connect these with appropriate innovations. Partners like IHA and R4D have been essential in helping us move forward in sourcing and selecting solutions, and we are now ready to address the challenges of financing their scale-up in stages 3 and 4 of the Mountain Model.”
Many barriers to systematizing innovation sourcing and scale-up within government still remain, however. As Dr Mahamud Eda (below), Chair of the Health Caucus within the Kenyan Council of Governors noted:
“As we continue transitioning towards a middle-income country, Kenya will soon be relying a lot more on domestic financing for health, yet we will always need the support of other partners to enable a sustainable and impactful response at scale. There are issues with our procurement processes that are hindering efficient decision-making and sourcing of solutions, and we need to ensure more counties are engaged and sharing learning around this process in order to exploit economies of scale. The IICs are therefore an important and timely initiative in helping us move forward through a ‘whole-of-government’ model” and ensure that we are not limited by the resources that individual counties may have available at any one time.”
The misalignment of existing procurement policies to innovation opportunities was also emphasized from the investor perspective by Robert Karanja (co-founder and Chief Innovation Officer at Villgro Africa), who highlighted a need to find both short-term pragmatic tools / approaches to address immediate issues (such as the IICs) while also continuing to advocate for more expansive changes to procurement policy in the longer-term through vehicles such as the 2021 Kenyan Start-Up Bill.
These contextual insights helpfully set the scene for the second half of the workshop, where participants broke into smaller groups to unpack and refine an initial structure for Innovation Investment Cases developed by the PSS Action Lab. Key points from this discussion included:
Being mindful of talking about innovation when some counties are already struggling to provide the basics, and making sure that IICs reflect an opportunity to accelerate / enhance commitment to those basics rather than operate in competition;
Identifying and engaging the right stakeholders in the IIC process early on to secure their buy-in and support for it to progress. This includes the more obvious actors from the Ministry of Health / Financing but also adjacent departments such as Treasury, Legal etc. and in particular health economists within or outside government who can be especially helpful in constructing cost-benefit analyses and arguments to support the IIC.
Recognising that the IICs are a potential platform for helping to change government mindsets and cultures around innovation, but that this will intensify the need for broader skills development and support for this approach to become sustainably integrated. As Dr Philip Mbithi, County PHC Coordinator for Trans Nzoia remarked, “The IICs are a fantastic idea, but it will take time for counties to embrace and adopt this model because they do not have direct experience of negotiating for funds from external partners in the way that the IICs require - for so long the money has come to us.”
Acknowledging that in addition to securing support from external partners, the IICs can also be a powerful internal advocacy tool to unlock resources from other parts of government;
Ensuring that the IICs effectively communicate the complementary “What’s in it for me?” angles relevant to the various target audiences (which include government, investors and the innovators);
Thinking carefully about the language used in the IIC to optimize its success within a context where everyone is competing for resources. As Ms. Agnes Tsuma (above, Manager Innovation Commercialization) from the Kenyan National Innovation Agency noted, “It is not enough to rely on articulating the benefit in terms of saving lives, we need to articulate why the IIC also makes clear business sense in terms of efficiency, cost-savings and return on investment for external partners.” This point was also supported by one of our PSS Lab Champions, Dr Francis Wafula from Strathmore University who confirmed “the IICs will help change the image of health actors within government - everyone sees us as doctors and nurses so the business structure of the IIC will help others take us more seriously.”
Being creative around designing the co-funding partnerships that an IIC might catalyze. For example, it was noted that Kenyan county governments can form companies to help receive and manage financing from external actors, and some counties such as Kajiado have already formed ‘County Investment Authorities’ that bring together investors who are supporting gov programs in different sectors.
Managing potential risks associated with an IIC addressing one particular health problem in an isolated way, and exploring the potential for multiple innovations to be considered as part of portfolio-style IICs that attract support for aggregated solutions.
Contextualizing the IIC within existing county gap analyses / strategic planning and articulating clear indicators of success for IIC investment. Many both within and outside the government are still skeptical about innovation because they are seeing very little meaningful progress in health outcomes despite years of sizable and sustained investment. As Dr Gregory Ganda, CECM (Minister) for Health Services from Kisumu county noted, “We need to move away from ‘briefcase innovators’ who ignore the current work we are doing and approach us as if we are operating in a vacuum - this is why the section of the IIC outlining the country context and demand will be so important.”
These are just some of the insightful points and recommendations collected from the workshop participants that will be fed into the next iteration of the IIC template and then used in the collaborative creation of IICs for Sanivation in Kajiado county and Vaccibox in Makueni county. As Alex Kilowua, the CECM (Minister) for Health Services in Kajiado, summarized in his closing remarks, “This has been a very good experience - being able to learn from other counties and exploring how to deepen our relationships with other potential investors and partners through the IICs. We are going home with a lot of knowledge, passion and drive towards leveraging innovation for universal health coverage.”
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If you are interested in supporting an IIC or the broader work of the Public Sector Scaling Action Lab to enhance government adoption of health innovation across East Africa, we would love to hear from you. Please contact Michael Nzungi, Manager of the PSS Lab, at mnzungi@r4d.org to learn more.
For more information on the Public Sector Scaling Action Lab for East Africa, visit https://www.idiainnovation.org/pss-action-lab
Written by: Thomas Feeny, Michael Nzungi, Paulina Adjei and Anna Giulia Ponchia
