Costs and effects of a multifaceted intervention to improve the quality of care of children in district hospitals in Kenya

In Kenya, an intervention to improve the quality of care of children was developed and tested in district hospitals. This was a multifaceted intervention employing clinical practice guidelines, training, supervision, feedback and facilitation, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. This thesis presents an economic evaluation of this complex intervention

Examining priority setting and resource allocation practices in county hospitals in Kenya

Hospitals consume a significant proportion of healthcare budgets and are a key avenue for the delivery of key interventions. Understanding how hospitals use resources is therefore an important question. Priority setting research has however focused on the macro (national) and micro (patient) level, and neglected the meso (organizational, hospital) level practices. There is also a dearth of literature on priority setting in developing country hospitals, although they are recognized to suffer severe resource scarcity. This thesis describes and evaluates priority setting practices in Kenyan hospitals and identifies strategies for improvement. METHODOLOGY: A case study approach was used, where two public hospitals in coastal Kenya were selected as cases and three priority setting processes examined as nested cases. Data were collected over a seven month fieldwork period using in - depth interviews, document reviews, and non - participant observations. A modified thematic approach was used for data analysis. FINDINGS: Hospitals exhibit properties of complex adaptive systems (CASs) that exist in a dynamic state with multiple interacting agents. Weaknesses in the system hardware (resource scarcity) and software (tangible - guidelines and procedure s and intangible - leadership and actor relationships) led to the emergence of undesired properties. Both hospitals had comparable system hardware and tangible software, but differences in intangible software contributed to variations in priority setting practices. For example, good leadership and actor relations in one hospital lead to better inclusion of stakeholders and perceptions of fairness while weak leadership, heightened tensions among actors and less inclusive processes in the other hospital lead to distrust and perceptions of unfairness. RECOMMENDATIONS: The capacity of hospitals to set priorities should be improved across the interacting aspects of organizational hardware, and tangible and intangible software. Interventions should however recognize that hospitals are CASs. Rather than rectifying isolated aspects of the system, they should endeavor to create conditions for productive emergence

What Is Resilience and How Can It Be Nurtured? A Systematic Review of Empirical Literature on Organizational Resilience.

BACKGROUND: Recent health system shocks such as the Ebola outbreak of 2014-2016 and the global financial crisis of 2008 have generated global health interest in the concept of resilience. The concept is however not new, and has been applied to other sectors for a longer period of time. We conducted a review of empirical literature from both the health and other sectors to synthesize evidence on organizational resilience. METHODS: We systematically searched for literature in PubMed, Econlit, EBSCOHOST databases, google, and Google Scholar and manually searched the reference lists of selected papers. We identified 34 papers that met our inclusion criteria. We analysed data from the selected papers by thematic review. RESULTS: Resilience was generally taken to mean a system's ability to continue to meet its objectives in the face of challenges. The concepts of resilience that were used in the selected papers emphasized not just a system's capacity to withstand shocks, but also to adapt and transform. The resilience of organizations was influenced by the following factors: Material resources, preparedness and planning, information management, collateral pathways and redundancy, governance processes, leadership practices, organizational culture, human capital, social networks and collaboration. CONCLUSION: A common theme across the selected papers is the recognition of resilience as an emergent property of complex adaptive systems. Resilience is both a function of planning for and preparing for future crisis (planned resilience), and adapting to chronic stresses and acute shocks (adaptive resilience). Beyond resilience to acute shocks, the resilience of health systems to routine and chronic stress (everyday resilience) is also key. Health system software is as, if not more important, as its hardware in nurturing health system resilience

The effects of health purchasing reforms on equity, access, quality of care, and financial protection in Kenya: a narrative review

Kenya has implemented several health purchasing reforms to facilitate progress toward universal health coverage. We conducted a narrative review of peer-reviewed and grey literature to examine how these reforms have affected health system outcomes in terms of equity, access, quality of care, and financial protection. We categorized the purchasing reforms we identified into the areas of benefits specification, provider payment, and performance monitoring. We found that the introduction and expansion of benefit packages for maternity, outpatient, and specialized services improved responsiveness to population needs and enhanced protection from financial hardship. However, access to service entitlements was limited by inadequate awareness of the covered services among providers and lack of service availability at contracted facilities. Provider payment reforms increased health facilities’ access to funds, which enhanced service delivery, quality of care, and staff motivation. But delays and the perceived inadequacy of payment rates incentivized negative provider behavior, which limited access to care and exposed patients to out-of-pocket payments. We found that performance monitoring reforms improved the quality assurance capacity of the public insurer and enhanced patient safety, service utilization, and quality of care provided by facilities. Although health purchasing reforms have improved access, quality of care, and financial risk protection to some extent in Kenya, they should be aligned and implemented jointly rather than as individual interventions. Measures that policymakers might consider include strengthening communication of health benefits, timely and adequate payment of providers, and enhancing health facility autonomy over the revenues they generate

Socioeconomic inequity in the screening and treatment of hypertension in Kenya: evidence from a national survey

Background: Non-communicable diseases (NCDs) account for 50% of hospitalisations and 55% of inpatient deaths in Kenya. Hypertension is one of the major NCDs in Kenya. Equitable access and utilisation of screening and treatment interventions are critical for reducing the burden of hypertension. This study assessed horizontal equity (equal treatment for equal need) in the screening and treatment for hypertension. It also decomposed socioeconomic inequalities in care use in Kenya. Methods: Cross-sectional data from the 2015 NCDs risk factors STEPwise survey, covering 4,500 adults aged 18–69 years were analysed. Socioeconomic inequality was assessed using concentration curves and concentration indices (CI), and inequity by the horizontal inequity (HI) index. A positive (negative) CI or HI value suggests a pro-rich (pro-poor) inequality or inequity. Socioeconomic inequality in screening and treatment for hypertension was decomposed into contributions of need [age, sex, and body mass index (BMI)] and non-need (wealth status, education, exposure to media, employment, and area of residence) factors using a standard decomposition method. Results: The need for hypertension screening was higher among poorer than wealthier socioeconomic groups (CI = −0.077; p < 0.05). However, wealthier groups needed hypertension treatment more than poorer groups (CI = 0.293; p <0.001). Inequity in the use of hypertension screening (HI = 0.185; p < 0.001) and treatment (HI = 0.095; p < 0.001) were significantly pro-rich. Need factors such as sex and BMI were the largest contributors to inequalities in the use of screening services. By contrast, non-need factors like the area of residence, wealth, and employment status mainly contributed to inequalities in the utilisation of treatment services. Conclusion: Among other things, the use of hypertension screening and treatment services in Kenya should be according to need to realise the Sustainable Development Goals for NCDs. Specifically, efforts to attain equity in healthcare use for hypertension services should be multi-sectoral and focused on crucial inequity drivers such as regional disparities in care use, poverty and educational attainment. Also, concerted awareness campaigns are needed to increase the uptake of screening services for hypertension

The influence of power and actor relations on priority setting and resource allocation practices at the hospital level in Kenya: a case study

Abstract Background Priority setting and resource allocation in healthcare organizations often involves the balancing of competing interests and values in the context of hierarchical and politically complex settings with multiple interacting actor relationships. Despite this, few studies have examined the influence of actor and power dynamics on priority setting practices in healthcare organizations. This paper examines the influence of power relations among different actors on the implementation of priority setting and resource allocation processes in public hospitals in Kenya. Methods We used a qualitative case study approach to examine priority setting and resource allocation practices in two public hospitals in coastal Kenya. We collected data by a combination of in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), review of documents such as hospital plans and budgets, minutes of meetings and accounting records, and non-participant observations in case study hospitals over a period of 7 months. We applied a combination of two frameworks, Norman Long’s actor interface analysis and VeneKlasen and Miller’s expressions of power framework to examine and interpret our findings Results The interactions of actors in the case study hospitals resulted in socially constructed interfaces between: 1) senior managers and middle level managers 2) non-clinical managers and clinicians, and 3) hospital managers and the community. Power imbalances resulted in the exclusion of middle level managers (in one of the hospitals) and clinicians and the community (in both hospitals) from decision making processes. This resulted in, amongst others, perceptions of unfairness, and reduced motivation in hospital staff. It also puts to question the legitimacy of priority setting processes in these hospitals. Conclusions Designing hospital decision making structures to strengthen participation and inclusion of relevant stakeholders could improve priority setting practices. This should however, be accompanied by measures to empower stakeholders to contribute to decision making. Strengthening soft leadership skills of hospital managers could also contribute to managing the power dynamics among actors in hospital priority setting processes

Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya.

BACKGROUND: Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality. METHODS: We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach. RESULTS: The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery. CONCLUSION: While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals

Crises and resilience at the frontline-public health facility managers under devolution in a sub-county on the Kenyan Coast

BACKGROUND: Public primary health care (PHC) facilities are for many individuals the first point of contact with the formal health care system. These facilities are managed by professional nurses or clinical officers who are recognised to play a key role in implementing health sector reforms and facilitating initiatives aimed at strengthening community involvement. Little in-depth research exists about the dimensions and challenges of these managers' jobs, or on the impact of decentralisation on their roles and responsibilities. In this paper, we describe the roles and responsibilities of PHC managers-or 'in-charges' in Kenya, and their challenges and coping strategies, under accelerated devolution. METHODS: The data presented in this paper is part of a wider set of activities aimed at understanding governance changes under devolution in Kenya, under the umbrella of a 'learning site'. A learning site is a long term process of collaboration between health managers and researchers deciding together on key health system questions and interventions. Data were collected through seven formal in depth interviews and observations at four PHC facilities as well as eight in depth interviews and informal interactions with sub-county managers from June 2013 to July 2014. Drawing on the Aragon framework of organisation capacity we discuss the multiple accountabilities, daily routines, challenges and coping strategies among PHC facility managers. RESULTS: PHC in-charges perform complex and diverse roles in a difficult environment with relatively little formal preparation. Their key concerns are lack of job clarity and preparedness, the difficulty of balancing multidirectional accountability responsibilities amidst significant resource shortages, and remuneration anxieties. We show that day-to-day management in an environment of resource constraints and uncertainty requires PHC in-charges who are resilient, reflective, and continuously able to learn and adapt. We highlight the importance of leadership development including the building of critical soft skills such as relationship building

What Is Resilience and How Can It Be Nurtured? A Systematic Review of Empirical Literature on Organizational Resilience

Abstract Background: Recent health system shocks such as the Ebola outbreak of 2014–2016 and the global financial crisis of 2008 have generated global health interest in the concept of resilience. The concept is however not new, and has been applied to other sectors for a longer period of time. We conducted a review of empirical literature from both the health and other sectors to synthesize evidence on organizational resilience. Methods: We systematically searched for literature in PubMed, Econlit, EBSCOHOST databases, google, and Google Scholar and manually searched the reference lists of selected papers. We identified 34 papers that met our inclusion criteria. We analysed data from the selected papers by thematic review. Results: Resilience was generally taken to mean a system’s ability to continue to meet its objectives in the face of challenges. The concepts of resilience that were used in the selected papers emphasized not just a system’s capacity to withstand shocks, but also to adapt and transform. The resilience of organizations was influenced by the following factors: Material resources, preparedness and planning, information management, collateral pathways and redundancy, governance processes, leadership practices, organizational culture, human capital, social networks and collaboration. Conclusion: A common theme across the selected papers is the recognition of resilience as an emergent property of complex adaptive systems. Resilience is both a function of planning for and preparing for future crisis (planned resilience), and adapting to chronic stresses and acute shocks (adaptive resilience). Beyond resilience to acute shocks, the resilience of health systems to routine and chronic stress (everyday resilience) is also key. Health system software is as, if not more important, as its hardware in nurturing health system resilience

Out of pocket payments during childbirth in Kenya under the free maternity services: Perspectives of mothers, healthcare workers and county officials

Background: This study seeks to determine the extent of women's out-of-pocket (OOP) payments for delivery under the free maternity policy (FMP). Methods: We conducted a convergent parallel mixed-methods study using quantitative and qualitative data collection. The study was set in three facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved exit interview (EI) surveys with mothers (n = 553) who utilised FMP delivery services and focus group discussions (FGDs) with mothers who returned for postnatal visits (6, 10, and 14 weeks). There were 21 in-depth interviews (IDIs) with county officials and healthcare workers (HCWs). Quantitative data were analysed using descriptive statistics, while qualitative data were audio-recorded, transcribed and analysed using thematic analysis. Results: Despite the FMP being free on paper, mothers incurred OOP payments in practice. The overall mean OOP payments incurred by mothers who underwent normal delivery was 9.50 USD (SD 8.20 USD), and caesarean section (CS) was 10.88 USD (SD 15.16 USD). The main cost drivers were transport, lack of adequate supply and medications, lack of policy clarity by health workers, failure to notify the NHIF office of available clients, and ultrasound scan services. While the OOP payments were not deemed catastrophic, some women perceived it as a barrier to care as they ended up using savings or selling their assets to meet the costs. There were no patient characteristics associated with OOP payments. Conclusions: OOP payments during childbirth in Kenya place a considerable economic burden on mothers and their households. There is need to promote awareness of the policy and provide a sustainable form of transport, especially during emergencies, through collaboration with partners. Prioritising the supply of required medication used in maternal services in the universal health care benefits package to which Kenyan citizens are entitled, or sustainably financing the FMP is crucial