Smart City, Just City
I was asked to guest blog on this topic by IHC Global as a part of their Smart City, Just City blog series leading up to the UN Habitat Assembly in Nairobi in May 2019.
It goes without saying that urban health is an essential component of the smart city conversion … But perhaps it does need saying again? Quality of life is improved by basic and effective health access and quality of life should be improved as a part of any smart city strategy.
However, ‘improving health’ can feel vague as a target, an overwhelming issue that is too hard, too multifaceted to tackle with any real impact especially for the 61% of urban Africans who live in slums [1]. My belief is that the smart integration of simple data-gathering digital tools into any healthcare approach can have extraordinary, ongoing impact, and health data should be routinely viewed alongside other urban data. Access Afya has been able to showcase a successful model for data gathering and use in urban slums at an extremely low cost; we have quantitatively and qualitatively proven that when combined with other urban initiatives, health impact is amplified. Here I will lay out how the smart health experience can inform strategy for creating Smart, Just cities.
The modern healthcare operating system for smart cities
Access Afya improves urban health by providing residents of Nairobi’s informal settlements with access to affordable, convenient and effective primary healthcare through a network of micro-clinics, pharmacies and field health workers. Our patients tend to work casually or for themselves, earning $2-5 per day. The average household in a Nairobi slum is a single room around 10ft x 10ft, housing 4-5 people.
We have created the “operating system” for community health which combines standard operating procedures; digital health tools such as mobile phone based ECG and telemedicine; community outreach, great customer care and a low-cost, customized tech stack to systematically deliver affordable, effective and convenient healthcare. This system is being used in our 12 sites and has helped us serve over 110,000 visits. Our clinics are fully digital, and we use operational and patient data to improve our service offerings and our operations.
Smart Cities + Smart Slums
Mark Deakin defines a smart city as one that utilizes ICT to meet the demands of its citizens, and that community involvement in its processes is a necessity for a smart city. But the same opportunities that exist to leverage ICT in a city can and should extend to its poorest citizens – those two thirds of urban Africans who live in slums. Right now, in Kenya, we can have a Smart Slum.
A Smart Slum model would entail deploying innovative and low-cost ways to gather information and responding to it to improve quality of life, just like Access Afya is doing for primary healthcare. This conversation about smart cities and their logical offspring, smart slums, is timely in Nairobi, where the government has pledged 500,000 affordable homes by 2021 and upgrades in sanitation and water for slums. A Smart Slum approach would maximize limited resources by using data to make the best investments and create engagement mechanisms for citizens creating a two-way dialog.
Smart Cities are about collecting data and then using data…smartly
Access Afya’s smart health system has prioritized measuring and using data, and creating real feedback loops with our patients. The proprietary digital systems are collecting operational, demographic, encounter, purchasing and outcomes data. Our “sensor network” of field workers, micro clinics and retail pharmacies have rich and longitudinal data on how communities are affected by various infectious disease, develop noninfectious diseases, respond to treatment and invest in preventative measures. This is being used constantly to tweak programs, respond to problems, and improve health outcomes for people.
For example, we have A/B tested different behavioral nudges to develop the best messaging strategy to lower blood pressure for our hypertensive patients. Through two-way SMS, we are in regular conversations with our patients using big data to track trends in what they want, or what trends in non-responsiveness to treatment are, and using small data to pick up the phone and call a patient to get qualitative feedback.
Healthy schools, Smart schools
The reality is that health is environmental and we have taken steps to incorporate this environmental awareness into our work. The most transformative program that Access Afya launched to address health determinants specifically challenging urban informal settlements, was a program called Healthy Schools. This program used a modular approach to health and wellness to create packages for schools that tied together WASH, health education, nutrition, early detection and prevention, high-quality clinical treatment for children who need it and insurance for worst-cast scenarios.
Healthy Schools started with malnutrition and feeding as a core part of program design. The idea was to ensure that the students had the nutrients their brains needed to learn, while also fighting malnutrition (1 in 5 children in Kenya are stunted) and ensuring regular access to deworming so that parasites don’t steal the small amounts of nutrients children consume.
Over time our data showed us that while one in three children in the program was malnourished, one in three was overweight. We adjusted programming to address this in our education.
In a partnership with Boehringer Ingelheim, Access Afya is developing diabetes and hypertension prevention programs which should start in grade school.
The program achieved solid results for health and education, increasing attendance in one school by 30 percentage points, increasing teacher-reported student energy levels, and reducing the number of children with health conditions that were being managed by around 40 percentage points. We can achieve astounding results when we work together to simultaneously link together things that urban poor families need while creating a virtuous cycle through reminder and support from classmates, teachers and parents.
Being smart with the basics
We don’t need much more data to start on the basics and ensure future smart cities can have the best chance of being healthy cities.
In Kenyan slums, the majority of households do not have access to basic sanitation. By 2012 we knew this: “A lack of sanitation leads to more disease, which leads to higher antibiotic use, which leads to greater resistance,” said Marc-Alain Widdowson, principal deputy director of the C.D.C.’s Division of Global Health Protection for Kenya [2]. We need to act to get basic sanitation into the crowded urban areas that act as a landing point for those moving to cities in search of better opportunities.
Air quality is important and can be worsened by cities and in slums. We are looking at merging our health data with air quality data to evaluate the relationship between air pollution and respiratory diagnosis rates.
Security is a concern for people and especially women who live in slums. Gender-based violence exacerbates other health challenges such as HIV and unplanned pregnancies. Information can make unsafe areas more secure or support the locations of counseling services, and groups like MediCapt are supporting clinics to better document evidence needed to hold perpetrators of sexual violence accountable.
While Kenya continues to fight infectious disease, it is seeing a rise in non-communicable diseases. Urban lifestyles and diets are theorized to be at least partially contributing to this. In the United States, clinical trials have found that African Americans respond differently to treatments and therefore we have adopted an African American protocol for our NCD patients. There needs to be rigorous clinical investigation into diversity within the African genome and effectiveness of different therapies here. We believe this is essential research as we fight the growing burden of NCDs and would like to participate with others to make this a reality.
Tackling the urban health challenge: why I care
I became interested in health from the perspective of urban development and prosperity. I worked for an affordable housing social enterprise in the US and for a consulting firm that existed to drive investment into low-income areas like East New York and Orange, New Jersey. Having lived in Kenya during my undergraduate degree and done the Peace Corps in Jordan, I was interested in urbanization in the global context and became drawn to slums, these byproducts of urbanization full of people looking for better lives and met with unsanitary and sometimes insecure environments.
You can’t walk five minutes without seeing a health shop in slums. The problem is that these shops are often run by people with no medical expertise, suspect drugs and prescribing practices and limited if any diagnostic tests. While the prevailing public narrative was that the poor wouldn’t pay for health, it only took a stroll around the slum to see that clearly was not the case.
I started Access Afya to create an alternative to informal health that is convenient, affordable and effective. We get deep into the communities we serve, creating jobs hyper-locally through our Clinic Assistant program and integrating our marketing and outreach into community clean-ups, pop-up diabetes and hypertension screenings, and speaking at local chief’s barazas (community meetings).
Smart cities will be just cities with the right approach to healthcare
Big data and community health agents work best when working together, and this high-tech, high-touch model is scalable for incorporation into smart cities and smart slums of the future. But the innovative healthcare solutions driven by private sector companies like Access Afya could amplify their impact enormously if embraced by the regional governments alongside which they operate, the public urban health agenda allowing everyone a safe foundation from which to thrive in the new global economy.
My vision of a smart, just city provides citizens a real voice into how a public sector allocates its resources and is responsive to the needs and wants of its people. For healthcare, this means that social and environmental determinants of health are addressed alongside affordable, effective treatment options and population level information ensures that the right public health investments are being made. If data is the voice of the people, a smart city can continuously see what is needed and a just city should respond to this.
1. https://www.un.org/africarenewal/magazine/april-2012/towards-african-cities-without-slums
2. “In a Poor Kenyan Community, Cheap Antibiotics Fuel Deadly Drug-Resistant Infections” https://www.nytimes.com/2019/04/07/health/antibiotic-resistance-kenya-drugs.html?action=click&module=Top%20Stories&pgtype=Homepage