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Health system accountability and primary health care delivery in rural Kenya. An analysis of the structures, PROCESS, and outcomes.
Globally, health systems accountability and engagement are increasingly claimed to be vital means to improve services by providing mechanisms for potential beneficiaries to contribute to the design, implementation, and evaluation of service delivery. In Kenya, these have taken the form of hospital boards, health facility committees, patient and facility service charters, and suggestion boxes. However, there is little information available on the factors that impact on the performance of such accountability mechanisms. This thesis addresses the shortfall, by investigating process issues that influence the performance of accountability initiatives.
Primary research was conducted in a rural district through a cross-sectional survey of households clustered around four public health facilities. Following a pilot study, data on accountability mechanisms supporting service delivery were collected through a mapping exercise involving in-depth interviews and facility audits. Data on the use of these were then collected through a large cross-sectional household survey, participant observation and focus group discussions. Analysis focused on accountability mechanisms within the health facilities and on issues around the relationship between those facilities and the local community. This was supplemented by user experiences of services where this was central to an understanding of accountability structures performance.
The research identified health facility committees and Service Charters as the main accountability mechanisms adopted. Further analysis showed that four main underlying factors - accessibility/proximity, trust, power and responsibility –influenced both of these. The context of the health system and cultural practices were also important determinants of performance, either constraining or enhancing their impact on service delivery.
These findings suggest that emphasis on the structure of accountability and engagement mechanisms, or adopting simple measures of outcome, are unlikely to account for how and why accountability mechanisms perform as they do. Processes that sustain and are sustained by accountability mechanisms need to be considered including the selection process of health facility committee members, the use of effective communication methods with the local community, and appropriate national regulation. In addition, these efforts should always take into account the health needs of the local population, their cultural practices, and the policy context within which these mechanisms are expected to operate.This PhD thesis was funded by the Gates Cambridge Trust, and substantially supported by Peterhouse Cambridge and the APHR
Strengthening health system governance using health facility service charters: a mixed methods assessment of community experiences and perceptions in a district in Kenya.
BACKGROUND: Enhancing accountability in health systems is increasingly emphasised as crucial for improving the nature and quality of health service delivery worldwide and particularly in developing countries. Accountability mechanisms include, among others, health facilities committees, suggestion boxes, facility and patient charters. However, there is a dearth of information regarding the nature of and factors that influence the performance of accountability mechanisms, especially in developing countries. We examine community members' experiences of one such accountability mechanism, the health facility charter in Kericho District, Kenya. METHODS: A household survey was conducted in 2011 among 1,024 respondents (36% male, 64% female) aged 17 years and above stratified by health facility catchment area, situated in a division in Kericho District. In addition, sixteen focus group discussions were conducted with health facility users in the four health facility catchment areas. Quantitative data were analysed through frequency distributions and cross-tabulations. Qualitative data were transcribed and analysed using a thematic approach. RESULTS: The majority (65%) of household survey respondents had seen their local facility service charter, 84% of whom had read the information on the charter. Of these, 83% found the charter to be useful or very useful. According to the respondents, the charters provided useful information about the services offered and their costs, gave users a voice to curb potential overcharging and helped users plan their medical expenses before receiving the service. However, community members cited several challenges with using the charters: non-adherence to charter provisions by health workers; illegibility and language issues; lack of expenditure records; lack of time to read and understand them, often due to pressures around queuing; and socio-cultural limitations. CONCLUSION: Findings from this study suggest that improving the compliance of health facilities in districts across Kenya with regard to the implementation of the facility service charter is critical for accountability and community satisfaction with service delivery. To improve the compliance of health facilities, attention needs to be focused on mechanisms that help enforce official guidelines, address capacity gaps, and enhance public awareness of the charters and their use