Potential Impact of devolution on motivation and job satisfaction of healthcare workers in Kenya: Lessons from early implementation in Kenya and experiences of other Sub-Saharan African Countries

Background: Kenya’s healthcare devolution was introduced to enhance the quality of care, user satisfaction, equity, and efficiency in service delivery. However, it has since been facing plethora of challenges mostly because healthcare workers (HCWs), who play a significant role in achieving health objectives, were neglected during implementation. Objectives: This dissertation tries to identify the potential impact of devolution on motivation and satisfaction of HCWs in a politicised Kenyan context. In the end, it will aid in formulating policies and recommendations to the government that will enhance worker’s job performance post-devolution. Methods: It uses media reports on Kenyan HCWs post-devolution and published academic research on Sub-Sahara Africa (SSA) countries decentralisation experiences to aid in inferring the prospective outcomes to the Kenyan context. Analysis of the literature aggregates some components of Franco et al.’s framework with Principal-Agent (P-A) theory to aids in clarifying the black box of motivation and satisfaction post-devolution in four broad channels: principal-agent relationship, organisation structure, and power and culture. Conclusion: A well-coordinated leadership is an indispensable tool that if crystalized together with good supervision and proper power play, will influence the achievement the goals of the healthcare system. The government needs to improve the “motivation factors” such recognition and growth besides promoting professional identity and status of HCWs. Kenyan HCWs need value-added culture of monitoring, transparent training and educational opportunities, and equal participation opportunities into a new county health administration to be able to achieve healthcare devolution objectives

Examining the quality of care across the continuum of maternal care (antenatal, perinatal, and postnatal care) under the expanded free maternity policy (Linda Mama Policy) in Kenya: a mixed-methods study

Background Kenya still faces the challenge of mothers and neonates dying from preventable pregnancy-related complications. The free maternity policy (FMP), implemented in 2013 and expanded in 2017 (Linda Mama Policy (LMP)), sought to address the challenge. This study examines the quality of care (QoC) across the continuum of maternal care under the LMP in Kenya. Methods We conducted a convergent parallel mixed-methods study across multiple levels of the Kenyan health system, involving key informant interviews (KIIs) with national stakeholders (n=15), in-depth interviews (IDIs) with county officials and healthcare workers (HCWs) (n=21), exit interview survey with mothers (n=553) who utilised the LMP delivery services, and focus group discussions (FGDs) (n=9) with mothers who returned for postnatal visits (at 6, 10, and 14 weeks). Quantitative data was analysed descriptively, while qualitative data was analysed thematically. All the data were triangulated at the analysis and discussion stage using a framework approach guided by the QoC for Maternal and Newborns. Results The results showed that the expanded FMP enhanced maternal care access: geographical, financial, and service utilisation. However, the facilities and HCWs bore the brunt of the increased workload and burnout. There was a longer waiting time for the initial visit by the pregnant women because of the enhanced antenatal care (ANC) package of the LMP. The availability and standards of equipment, supplies, and infrastructure still posed challenges. Nurses were multitasking and motivated despite the human resources challenge. Mothers were happy to have received care information; however, there were challenges regarding respect and dignity they received (inadequate food, over-crowding, bed-sharing and lack of privacy), and they experienced physical, verbal, and emotional abuse and a lack of attention/care. Conclusions Addressing the negative aspects of QoC while strengthening the positives is necessary to achieve the UHC goals through better quality service for every woman

Effects of free maternal policies on quality and cost of care and outcomes: an integrative review

Aim: We conducted an integrative review of the global-free maternity (FM) policies and evaluated the quality of care (QoC) and cost and cost implications to provide lessons for universal health coverage (UHC). Methodology: Using integrative review methods proposed by Whittemore and Knafl (2005), we searched through EBSCO Host, ArticleFirst, Cochrane Central Registry of Controlled Trials, Emerald Insight, JSTOR, PubMed, Springer Link, Electronic collections online, and Google Scholar databases guided by the preferred reporting item for systematic review and meta-analysis protocol (PRISMA) guideline. Only empirical studies that described FM policies with components of quality and cost were included. There were 43 papers included, and the data were analysed thematically. Results: Forty-three studies that met the criteria were all from developing countries and had implemented different approaches of FM policy. Review findings demonstrated that some of the quality issues hindering the policies were poor management of complications, worsened referral systems, overburdening of staff because of increased utilisation, lack of transport, and low supply of stock. There were some quality improvements on monitoring vital signs by nurses and some procedures met the recommended standards. Equally, mothers still bear the burden of some costs such as the purchase of drugs, transport, informal payments despite policies being ‘free’. Conclusions: FM policies can reduce the financial burden on the households if well implemented and sustainably funded. Besides, they may also contribute to a decline in inequity between the rich and poor though not independently. In order to achieve the SDG goal of UHC by 2030, there is a need to promote awareness of the policy to the poor and disadvantaged women in rural areas to help narrow the inequality gap on utilisation and provide a sustainable form of transport through collaboration with partners to help reduce impoverishment of households. Also, there is a need to address elements such as cultural barriers and the role of traditional birth attendants which hinder women from seeking skilled care even when they are freely available

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

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

Examining the quality of care across the continuum of maternal care (antenatal, perinatal and postnatal care) under the expanded free maternity policy (Linda Mama Policy) in Kenya: a mixed-methods study.

Kenya still faces the challenge of mothers and neonates dying from preventable pregnancy-related complications. The free maternity policy (FMP), implemented in 2013 and expanded in 2017 (Linda Mama Policy (LMP)), sought to address this challenge. This study examines the quality of care (QoC) across the continuum of maternal care under the LMP in Kenya. We conducted a convergent parallel mixed-methods study across multiple levels of the Kenyan health system, involving key informant interviews with national stakeholders (n=15), in-depth interviews with county officials and healthcare workers (HCWs) (n=21), exit interview survey with mothers (n=553) who utilised the LMP delivery services, and focus group discussions (n=9) with mothers who returned for postnatal visits (at 6, 10 and 14 weeks). Quantitative data were analysed descriptively, while qualitative data were analysed thematically. All the data were triangulated at the analysis and discussion stage using a framework approach guided by the QoC for maternal and newborns. The results showed that the expanded FMP enhanced maternal care access: geographical, financial and service utilisation. However, the facilities and HCWs bore the brunt of the increased workload and burnout. There was a longer waiting time for the initial visit by the pregnant women because of the enhanced antenatal care package of the LMP. The availability and standards of equipment, supplies and infrastructure still posed challenges. Nurses were multitasking and motivated despite the human resources challenge. Mothers were happy to have received care information; however, there were challenges regarding respect and dignity they received (inadequate food, over-crowding, bed-sharing and lack of privacy), and they experienced physical, verbal and emotional abuse and a lack of attention/care. Addressing the negative aspects of QoC while strengthening the positives is necessary to achieve the Universal Health Coverage goals through better quality service for every woman

Examining the implementation of the Linda Mama free maternity program in Kenya

Background In 2013, Kenya introduced a free maternity policy in all public healthcare facilities. In 2016, the Ministry of Health shifted responsibility for the program, now called Linda Mama, to the National Hospital Insurance Fund (NHIF) and expanded access beyond public sector. This study aimed to examine the implementation of the Linda Mama program. Methods We conducted a mixed-methods cross-sectional study at the national level and in 20 purposively sampled facilities across five counties in Kenya. We collected data using in-depth interviews (n = 104), administered patient-exit questionnaires (n = 108), and carried out document reviews. Qualitative data were analysed using a framework approach while quantitative data were analysed descriptively. Results Linda Mama was designed and resulted in improved accountability and expand benefits. In practice however, beneficiaries did not access some services that were part of the revised benefit package. Second, out of pocket payments were still being incurred by beneficiaries. Health facilities in most counties had lost financial autonomy and had no access to reimbursements from NHIF for services provided; but those with financial autonomy were able to boost facility revenue and enhance service delivery. Further, fund disbursements from NHIF were characterised by delays and unpredictability. Implementation experiences reveal that there was inadequate communication, claim processing challenges and reimbursement rates were deemed insufficient

Exploring the adaptations of the free maternity policy implementation by health workers and county officials in Kenya

In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to maternal services in private, faith-based, and levels 3-6 public institutions. We explored the adaptive strategies health care workers (HCWs) and county officials used to bridge the implementation challenges and achieve the FMP objectives. We conducted an exploratory qualitative study using Lipsky's theoretical framework in 3 facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved in-depth interviews (n=21) with county officials, facility in-charges and HCWs, and key informants from national and development partner agencies. Data were audio-recorded, transcribed, and analyzed using a framework thematic approach. The results show that HCWs and county officials applied several strategies that were critical in shaping the policymaking, working practice, and professionalism and ethical aspects of the FMP. Strategies of policymaking: hospitals employed additional staff, and the county developed bylaws to strengthen the flow of funds. Strategies of working practice: hospitals and HCWs enhanced patient referrals, and facilities enhanced communication. Strategies of professionalism and ethics: nurses registered and provided service to mothers, and facilities included employees in planning and budgeting. Maladaptations included facilities having leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some discharged mothers immediately after birth, even before offering the fully costed policy benefits, to avoid incurring additional costs. The role of policy implementers and the built-in flexibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementation, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended consequences may need interventions. [Abstract copyright: © Oyugi et al.

Improving the management of hypertension and diabetes: An implementation evaluation of an electronic medical record system in Nairobi County, Kenya

Objective To evaluate the implementation of a novel electronic medical record (EMR) system for management of non-communicable diseases (NCD) (hypertension (HTN) and diabetes mellitus (DM)) in health facilities in informal settlements in Nairobi. Questions of interest were on the use of, perception of the HCWs, and scalability and sustainability of the EMR system. Method The study utilised a descriptive and analytical implementation evaluation through a convergent parallel mixed-methods design in 33 health facilities in the informal settlements in Nairobi County, Kenya. We carried out semi-structured interviews with the county and sub-county health management staff (n = 9), facility in-charges (n = 8), healthcare workers (HCW) (n = 35), and project staff (n = 7). Additionally, quantitative analysis, trend analysis, critical evaluation and costing were done. Qualitative data were analysed thematically using NVIVO while quantitative data were analysed using Excel and Stata software. Results The EMR system significantly improved data capture and management of HTN and DM patients. The system helped clinicians to adhere to treatment and management guidelines and in clinical decision making. Most HCWs had a positive attitude and perceptions about the EMR system, and it was a good initiative for improving the quality and standardisation of care. The data captured made it easier to generate health facility and clinics reports which were essential for planning and decision-making processes. A critical audit of the EMR system features showed adequate general design features (data elements, structure and organisation, ease of use, accessibility, interfaces, confidentiality, access limitation, accuracy and integrity). Discussion Use of the EMR helped in improving patients care. The technology not only enhanced assurance of patients’ information safety and availability but also supported in clinical decision making and standardisation of care. Successful implementation of the technology is dependent on positive perception and attitude of the HCWs. While the initial cost of setting and managing the EMR is high, future maintenance cost could be lower, making it sustainable in the long run. However, it is vital for future implementors to source for adequate funds to run it to completion if it is to achieve its objective

Coordination mechanisms for COVID-19 in the WHO Regional office for Africa

Aim: this study describes the coordination mechanisms that have been used for management of the COVID-19 pandemic in the WHO AFRO region; relate the patterns of the disease (length of time between onset of coordination and first case; length of the wave of the disease and peak attack rate) to coordination mechanisms established at the national level, and document best practices and lessons learned. Method: We did a retrospective policy tracing of the COVID-19 coordination mechanisms from March 2020 (when first cases of COVID-19 in the AFRO region were reported) to the end of the third wave in September 2021. Data sources were from document and Literature review of COVID-19 response strategies, plans, regulations, press releases, government websites, grey and peer-reviewed literature. The data was extracted to Excel file database and coded then analysed using Stata (version 15). Analysis was done through descriptive statistical analysis (using measures of central tendencies (Mean, DS, and median) and measures of central dispersion (range)), multiple linear regression, and thematic analysis of qualitative data. Results: There are three distinct layered coordination mechanisms (strategic, operational, and tactical) that were either implemented singularly or in tandem with another coordination mechanism. 87.23% (n=41) of the countries initiated strategic coordination, and 59.57% (n=28) initiated some form of operational coordination. Some of countries (n=26,55.32%) provided operational coordination using functional Public Health Emergency Operation Centres (PHEOCs) which were activated for the response. 31.91% (n=15) of the countries initiated some form of tactical coordination which involved the decentralisation of the operations at the local/grassroot level/district/ county levels. Decentralisation strategies played a key role in coordination, as was the innovative strategies by the countries; some coordination mechanisms built on already existing coordination systems and the heads of states were effective in the success of the coordination process. Financing posed challenge to majority of the countries in initiating coordination. Conclusion: Coordinating an emergency is a multidimensional process that includes having decision-makers and institutional agents define and prioritise policies and norms that contain the spread of the disease, regulate activities and behaviour and citizens, and respond to personnel who coordinate prevention