A Critical Analysis of Purchasing Arrangements in Kenya: The Case of the National Hospital Insurance Fund

Abstract Background: Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries (LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the National Hospital Insurance Fund (NHIF) as a case study. Methods: We applied a principal-agent relationship framework, which identifies three pairs of principal-agent relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through document reviews (statutes, policy and regulatory documents) and in-depth interviews (n=62) with key informants including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers. Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed using a thematic framework approach. Results: The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting, monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist, they do not always function appropriately and awareness of these channels to the beneficiaries is limited. Conclusion: Addressing the gaps in the NHIF’s purchasing performance requires a number of approaches. Critically, there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the multiplicity of actors given Kenya’s devolved context. Relatively recent decentralisation reforms present an opportunity that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal health coverage (UHC)

Clinical and Epidemiological Implications of 24-Hour Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Kenyan Adults: A Population-Based Study.

BACKGROUND: The clinical and epidemiological implications of using ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension have not been studied at a population level in sub-Saharan Africa. We examined the impact of ABPM use among Kenyan adults. METHODS AND RESULTS: We performed a nested case-control study of diagnostic accuracy. We selected an age-stratified random sample of 1248 adults from the list of residents of the Kilifi Health and Demographic Surveillance System in Kenya. All participants underwent a screening blood pressure (BP) measurement. All those with screening BP ≥140/90 mm Hg and a random subset of those with screening BP <140/90 mm Hg were invited to undergo ABPM. Based on the 2 tests, participants were categorized as sustained hypertensive, masked hypertensive, "white coat" hypertensive, or normotensive. Analyses were weighted by the probability of undergoing ABPM. Screening BP ≥140/90 mm Hg was present in 359 of 986 participants, translating to a crude population prevalence of 23.1% (95% CI 16.5-31.5%). Age standardized prevalence of screening BP ≥140/90 mm Hg was 26.5% (95% CI 19.3-35.6%). On ABPM, 186 of 415 participants were confirmed to be hypertensive, with crude prevalence of 15.6% (95% CI 9.4-23.1%) and age-standardized prevalence of 17.1% (95% CI 11.0-24.4%). Age-standardized prevalence of masked and white coat hypertension were 7.6% (95% CI 2.8-13.7%) and 3.8% (95% CI 1.7-6.1%), respectively. The sensitivity and specificity of screening BP measurements were 80% (95% CI 73-86%) and 84% (95% CI 79-88%), respectively. BP indices and validity measures showed strong age-related trends. CONCLUSIONS: Screening BP measurement significantly overestimated hypertension prevalence while failing to identify ≈50% of true hypertension diagnosed by ABPM. Our findings suggest significant clinical and epidemiological benefits of ABPM use for diagnosing hypertension in Kenyan adults

Burden of disease in adults admitted to hospital in a rural region of coastal Kenya: an analysis of data from linked clinical and demographic surveillance systems

Background Estimates of the burden of disease in adults in sub-Saharan Africa largely rely on models of sparse data. We aimed to measure the burden of disease in adults living in a rural area of coastal Kenya with use of linked clinical and demographic surveillance data. Methods We used data from 18 712 adults admitted to Kilifi District Hospital (Kilifi , Kenya) between Jan 1, 2007, and Dec 31, 2012, linked to 790 635 person-years of observation within the Kilifi Health and Demographic Surveillance System, to establish the rates and major causes of admission to hospital. These data were also used to model diseasespecifi c disability-adjusted life-years lost in the population. We used geographical mapping software to calculate admission rates stratifi ed by distance from the hospital. Findings The main causes of admission to hospital in women living within 5 km of the hospital were infectious and parasitic diseases (303 per 100 000 person-years of observation), pregnancy-related disorders (239 per 100 000 personyears of observation), and circulatory illnesses (105 per 100 000 person-years of observation). Leading causes of hospital admission in men living within 5 km of the hospital were infectious and parasitic diseases (169 per 100 000 personyears of observation), injuries (135 per 100 000 person-years of observation), and digestive system disorders (112 per 100 000 person-years of observation). HIV-related diseases were the leading cause of disability-adjusted lifeyears lost (2050 per 100 000 person-years of observation), followed by non-communicable diseases (741 per 100 000 personyears of observation). For every 5 km increase in distance from the hospital, all-cause admission rates decreased by 11% (95% CI 7–14) in men and 20% (17–23) in women. The magnitude of this decline was highest for endocrine disorders in women (35%; 95% CI 22–46) and neoplasms in men (30%; 9–45). Interpretation Adults in rural Kenya face a combined burden of infectious diseases, pregnancy-related disorders, cardiovascular illnesses, and injuries. Disease burden estimates based on hospital data are aff ected by distance from the hospital, and the amount of underestimation of disease burden diff ers by both disease and sex

FLUXNET: A New Tool to Study the Temporal and Spatial Variability of Ecosystem-Scale Carbon Dioxide, Water Vapor, and Energy Flux Densities

FLUXNET is a global network of micrometeorological flux measurement sites that measure the exchanges of carbon dioxide, water vapor, and energy between the biosphere and atmosphere. At present over 140 sites are operating on a long-term and continuous basis. Vegetation under study includes temperate conifer and broadleaved (deciduous and evergreen) forests, tropical and boreal forests, crops, grasslands, chaparral, wetlands, and tundra. Sites exist on five continents and their latitudinal distribution ranges from 70°N to 30°S. FLUXNET has several primary functions. First, it provides infrastructure for compiling, archiving, and distributing carbon, water, and energy flux measurement, and meteorological, plant, and soil data to the science community. (Data and site information are available online at the FLUXNET Web site, http://www-eosdis.ornl.gov/FLUXNET/.) Second, the project supports calibration and flux intercomparison activities. This activity ensures that data from the regional networks are intercomparable. And third, FLUXNET supports the synthesis, discussion, and communication of ideas and data by supporting project scientists, workshops, and visiting scientists. The overarching goal is to provide information for validating computations of net primary productivity, evaporation, and energy absorption that are being generated by sensors mounted on the NASA Terra satellite. Data being compiled by FLUXNET are being used to quantify and compare magnitudes and dynamics of annual ecosystem carbon and water balances, to quantify the response of stand-scale carbon dioxide and water vapor flux densities to controlling biotic and abiotic factors, and to validate a hierarchy of soil-plant-atmosphere trace gas exchange models. Findings so far include 1) net C02 exchange of temperate broadleaved forests increases by about 5.7 g C m~2 day-1 for each additional day that the growing season is extended; 2) the sensitivity of net ecosystem C02 exchange to sunlight doubles if the sky is cloudy rather than clear; 3) the spectrum of C02 flux density exhibits peaks at timescales of days, weeks, and years, and a spectral gap exists at the month timescale; 4) the optimal temperature of net C02 exchange varies with mean summer temperature; and 5) stand age affects carbon dioxide and water vapor flux densities

Risk of Injection-Site Abscess among Infants Receiving a Preservative-Free, Two-Dose Vial Formulation of Pneumococcal Conjugate Vaccine in Kenya.

There is a theoretical risk of adverse events following immunization with a preservative-free, 2-dose vial formulation of 10-valent-pneumococcal conjugate vaccine (PCV10). We set out to measure this risk. Four population-based surveillance sites in Kenya (total annual birth cohort of 11,500 infants) were used to conduct a 2-year post-introduction vaccine safety study of PCV10. Injection-site abscesses occurring within 7 days following vaccine administration were clinically diagnosed in all study sites (passive facility-based surveillance) and, also, detected by caregiver-reported symptoms of swelling plus discharge in two sites (active household-based surveillance). Abscess risk was expressed as the number of abscesses per 100,000 injections and was compared for the second vs first vial dose of PCV10 and for PCV10 vs pentavalent vaccine (comparator). A total of 58,288 PCV10 injections were recorded, including 24,054 and 19,702 identified as first and second vial doses, respectively (14,532 unknown vial dose). The risk ratio for abscess following injection with the second (41 per 100,000) vs first (33 per 100,000) vial dose of PCV10 was 1.22 (95% confidence interval [CI] 0.37-4.06). The comparator vaccine was changed from a 2-dose to 10-dose presentation midway through the study. The matched odds ratios for abscess following PCV10 were 1.00 (95% CI 0.12-8.56) and 0.27 (95% CI 0.14-0.54) when compared to the 2-dose and 10-dose pentavalent vaccine presentations, respectively. In Kenya immunization with PCV10 was not associated with an increased risk of injection site abscess, providing confidence that the vaccine may be safely used in Africa. The relatively higher risk of abscess following the 10-dose presentation of pentavalent vaccine merits further study

A Critical Assessment of the Implications of Devolution on Fiscal Space for Health at County Level in Kenya

Sufficient public expenditure on health (PHE) is critical to the attainment of universal health coverage (UHC). Fiscal space for health is the capability of a government to assign more resources to PHE without affecting its financial and economic position. Decentralisation arrangements have implications for PHE and therefore for fiscal space for health. This thesis critically assessed the implications of decentralisation on fiscal space for health at subnational (county government) level in Kenya and its implications on the attainment of UHC. A convergent parallel mixed methods design was used informed by a conceptual framework that guided the collection, analysis and integration of the results. Qualitative data were collected using a multiple case study approach with a focus on fiscal arrangements and changes in the government-citizen relationship. The units of analysis were 3 purposively selected counties. Data collection was through document reviews, interviews with key informants and focus group discussions. Data analysis was using a thematic analysis method. Quantitative data were from panel data regression analysis of secondary data of PHE of all 47 county governments spanning three financial years (FY 2014/15 to FY 2016/17). The integration of mixed methods arms was performed through a narrative weaving approach. Fiscal space for health was limited across all the case study counties evidenced by unchanging levels of per capita PHE and county government health expenditure as a proportion of total county government expenditure over time. There is overlap and poor coordination in performance of functions and challenges in revenue assignments, with potentially constricting effects on fiscal space for health. PHE was also potentially discouraged by inappropriate public finance arrangements and low capacity for planning and budgeting e.g. fixed ratios on development and recurrent spending. Well designed and implemented conditional grants potentially encouraged growth in PHE but their effect was blunted by those that were poorly designed and implemented. Narrowly defined and poorly applied mechanisms for social accountability potentially discouraged PHE. Significant and contextual challenges in the application of electoral accountability were observed with unclear implications on PHE. the determinants of per capita public health expenditure at county level in Kenya are per capita total conditional grant, per capita share of equitable revenue and per capita conditional grant. From the random effects model there is the strongest evidence that a 1% change in per capita total conditional grant results in a 0.09% (p <0.001, 95% CI 0.04% – 0.14%) change on per capita public health expenditure by county governments; and that a 1% change in per capita equitable share results in a 0.68% (p<0.001, 95% CI 0.45% - 0.92%) change in per capita public health expenditure by county governments. Decentralisation, mediated through fiscal arrangements and changes in the government-citizen relationship, has not increased fiscal space for health at decentralised level in Kenya. Better-functioning organisations and institutional arrangements that support these two mediators may expand fiscal space for health at this level. The design and operationalisation of vertical transfers and of conditional grants is critical. Strengthening of accountability mechanisms through a move to strategic social accountability may also contribute to increased fiscal space for health

Managing quality and standards in UK higher education Approaches to self-evaluation and self-regulation

SIGLEAvailable from British Library Document Supply Centre-DSC:q97/16583 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

A critical analysis of purchasing arrangements in Kenya: the case of micro health insurance

Abstract Background Strategic purchasing can ensure that financial resources are used in a way that optimally enhances the attainment of health system goals. A number of low- and middle-income countries, including Kenya, have experimented with micro health insurance (MHIs) as a means to purchase health services for the informal sector. This study aimed to examine the purchasing practices of MHIs in Kenya. Methods The study was guided by an analytical framework that compared purchasing practices of MHIs with the ideal actions for strategic purchasing along three pairs of principal-agent relationships (government-purchaser, purchaser-provider and citizen-purchaser). The study adopted a qualitative descriptive case study design with 2 MHIs as cases. Data were collected through document reviews (regulation, marketing materials, websites) and semi-structured interviews with key informants (n = 27). Results The regulatory framework for MHIs did not adequately support strategic purchasing practice and was exacerbated by poor coordination between health and financial sectors. The MHIs strategically contracted health providers over whom they could exercise bargaining power, sometimes at the expense of quality. There were no clear channels for beneficiaries to provide timely feedback to the purchaser. MHIs premium payments were family-based, low-cost and offered limited benefits. Coverage was based on ability to pay, which may have excluded low-income households from membership. Conclusions Adequate policy, legal and regulatory frameworks that integrate MHIs into the broader health financing system and support strategic purchasing practices are required. The state departments responsible for finance and health should form coordinating structures that ensure that MHI’s role in universal health coverage is owned across all relevant sectors, and that actors, such as regulators, perform in a coordinated manner. The frameworks should also seek to align purchasers’ relationships with providers so that clear and consistent signals are received by providers from all purchasing mechanisms present within the health system

A Critical Analysis of Purchasing Arrangements in Kenya: The Case of the National Hospital Insurance Fund

Background Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries (LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the National Hospital Insurance Fund (NHIF) as a case study. Methods We applied a principal-agent relationship framework, which identifies three pairs of principal-agent relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through document reviews (statutes, policy and regulatory documents) and in-depth interviews (n = 62) with key informants including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers. Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed using a thematic framework approach. Results The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting, monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist, they do not always function appropriately and awareness of these channels to the beneficiaries is limited. Conclusion Addressing the gaps in the NHIF’s purchasing performance requires a number of approaches. Critically, there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the multiplicity of actors given Kenya’s devolved context. Relatively recent decentralisation reforms present an opportunity that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal health coverage (UHC)

Understanding factors influencing the use of clinical guidelines in low-income and middle-income settings: a scoping review

Objective A scoping review was undertaken to determine the extent to which existing studies have examined factors influencing healthcare providers’ use of clinical guidelines in low and middle-income country (LMIC) settings and determine which factors constrain or facilitate the use of clinical guidelines by healthcare providers.Design Scoping review.Data sources The literature search was conducted using PubMed in January 2021.Eligibility criteria We identified empirical studies, published between 2011–2021 in English, which included clinicians and/or nurses as healthcare providers, used a health facility as the study site, and were located in an LMIC.Data extraction and synthesis Information extracted from the literature review was organised using themes and the findings synthesised using thematic analysis.Results The review identified five types of interacting factors that influence healthcare providers’ use of and compliance with clinical guidelines. The factors identified are organisational factors, factors relating to individual healthcare providers, attributes of the clinical guidelines, patient-related factors and institutional factors. Organisational factors can be further divided into the physical work environment, organisational culture and working conditions. The effective use of clinical guidelines in LMIC settings is greatly impacted by the contextualisation of clinical guidelines, end-user engagement and alignment of the implementation of clinical guidelines with the institutional arrangements in the broader health system.Conclusion The development and evaluation of concrete interventions is vital to facilitate the implementation of clinical guidelines and improve healthcare service quality. Further studies are necessary to examine the relative importance of the five identified factors on the effective use of clinical guidelines in different contexts