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COVID-19 vaccination rates have been low among adults in Kenya (36.7% as of late March 2023) with vaccine hesitancy posing a threat to the COVID-19 vaccination program. This study sought to examine facilitators and barriers to COVID-19 vaccinations in Kenya. We conducted a qualitative cross-sectional study in two purposively selected counties in Kenya. We collected data through 8 focus group discussions with 80 community members and 8 in-depth interviews with health care managers and providers. The data was analyzed using a framework approach focusing on determinants of vaccine hesitancy and their influence on psychological constructs. Barriers to COVID-19 vaccine uptake were related to individual characteristics (males, younger age, perceived health status, belief in herbal medicine, and the lack of autonomy in decision making among women - especially in rural settings), contextual influences (lifting of bans, myths, medical mistrust, cultural and religious beliefs), and COVID-19 vaccine related factors (fear of unknown consequences, side-effects, lack of understanding on how vaccines work and rationale for boosters). However, community health volunteers, trusted leaders, mandates, financial and geographic access influenced COVID-19 vaccine uptake. These drivers of hesitancy mainly related to psychological constructs including confidence, complacency, and constraints. Vaccine hesitancy in Kenya is driven by multiple interconnected factors. These factors are likely to inform evidence-based targeted strategies that are built on trust to address vaccine hesitancy. These strategies could include gender responsive immunization programs, appropriate messaging and consistent communication that target fear, safety concerns, misconceptions and information gaps in line with community concerns. There is need to ensure that the strategies are tested in the local setting and incorporate a multisectoral approach including community health volunteers, religious leaders and community leaders.
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Provider payment methods are traditionally examined by appraising the incentive signals inherent in individual payment mechanisms. However, mixed payment arrangements, which result in multiple funding flows from purchasers to providers, could be better understood by applying a systems approach that assesses the combined effects of multiple payment streams on healthcare providers. Guided by the framework developed by Barasa et al. (2021) (Barasa E, Mathauer I, Kabia E et al. 2021. How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them. Health Policy and Planning 36: 861-8.), this paper synthesizes the findings from six country case studies that examined multiple funding flows and describes the potential effect of multiple payment streams on healthcare provider behaviour in low- and middle-income countries. The qualitative findings from this study reveal the extent of undesirable provider behaviour occurring due to the receipt of multiple funding flows and explain how certain characteristics of funding flows can drive the occurrence of undesirable behaviours. Service and resource shifting occurred in most of the study countries; however, the occurrence of cost shifting was less evident. The perceived adequacy of payment rates was found to be the strongest driver of provider behaviour in the countries examined. The study results indicate that undesirable provider behaviours can have negative impacts on efficiency, equity and quality in healthcare service provision. Further empirical studies are required to add to the evidence on this link. In addition, future research could explore how governance arrangements can be used to coordinate multiple funding flows, mitigate unfavourable consequences and identify issues associated with the implementation of relevant governance measures.
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Países en Desarrollo , Personal de Salud , Humanos , Kenia , Nigeria , Burkina Faso , Marruecos , Túnez , VietnamRESUMEN
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.
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Administración Financiera , Cobertura Universal del Seguro de Salud , Femenino , Gastos en Salud , Humanos , Kenia , Embarazo , Calidad de la Atención de SaludRESUMEN
BACKGROUND: The COVID-19 pandemic and country measures to control it can lead to negative indirect health effects. Understanding these indirect health effects is important in informing strategies to mitigate against them. This paper presents an analysis of the indirect health effects of the pandemic in Kenya. METHODS: We employed a mixed-methods approach, combining the analysis of secondary quantitative data obtained from the Kenya Health Information System database (from January 2019 to November 2020) and a qualitative inquiry involving key informant interviews (n = 12) and document reviews. Quantitative data were analysed using an interrupted time series analysis (using March 2020 as the intervention period). Thematic analysis approach was employed to analyse qualitative data. RESULTS: Quantitative findings show mixed findings, with statistically significant reduction in inpatient utilization, and increase in the number of sexual violence cases per OPD visit that could be attributed to COVID-19 and its mitigation measures. Key informants reported that while financing of essential health services and domestic supply chains were not affected, international supply chains, health workforce, health infrastructure, service provision, and patient access were disrupted. However, the negative effects were thought to be transient, with mitigation measures leading to a bounce back. CONCLUSION: Finding from this study provide some insights into the effects of the pandemic and its mitigation measures in Kenya. The analysis emphasizes the value of strategies to minimize these undesired effects, and the critical role that routine health system data can play in monitoring continuity of service delivery.
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COVID-19 , Pandemias , Humanos , Kenia/epidemiología , Pandemias/prevención & control , Investigación Cualitativa , SARS-CoV-2RESUMEN
BACKGROUND: The COVID-19 pandemic has led to an unprecedented global research effort to build a body of knowledge that can inform mitigation strategies. We carried out a bibliometric analysis to describe the COVID-19 research output in Africa in terms of setting, study design, research themes and author affiliation. METHODS: We searched for articles published between 1 December 2019 and 3 January 2021 from various databases including PubMed, African Journals Online, medRxiv, Collabovid, the WHO global research database and Google. All article types and study design were included. RESULTS: A total of 1296 articles were retrieved. 46.6% were primary research articles, 48.6% were editorial-type articles while 4.6% were secondary research articles. 20.3% articles used the entire continent of Africa as their study setting while South Africa (15.4%) was the most common country-focused setting. The most common research topics include 'country preparedness and response' (24.9%) and 'the direct and indirect health impacts of the pandemic' (21.6%). However, only 1.0% of articles focus on therapeutics and vaccines. 90.3% of the articles had at least one African researcher as author, 78.5% had an African researcher as first author, while 63.5% had an African researcher as last author. The University of Cape Town leads with the greatest number of first and last authors. 13% of the articles were published in medRxiv and of the studies that declared funding, the Wellcome Trust was the top funding body. CONCLUSIONS: This study highlights Africa's COVID-19 research and the continent's existing capacity to carry out research that addresses local problems. However, more studies focused on vaccines and therapeutics are needed to inform local development. In addition, the uneven distribution of research productivity among African countries emphasises the need for increased investment where needed.
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Bibliometría , Investigación Biomédica , COVID-19 , África/epidemiología , COVID-19/epidemiología , HumanosRESUMEN
Provider payment methods are a key health policy lever because they influence healthcare provider behaviour and affect health system objectives, such as efficiency, equity, financial protection and quality. Previous research focused on analysing individual provider payment methods in isolation, or on the actions of individual purchasers. However, purchasers typically use a mix of provider payment methods to pay healthcare providers and most health systems are fragmented with multiple purchasers. From a health provider perspective, these different payments are experienced as multiple funding flows which together send a complex set of signals about where they should focus their effort. In this article, we argue that there is a need to expand the analysis of provider payment methods to include an analysis of the interactions of multiple funding flows and the combined effect of their incentives on the provision of healthcare services. The purpose of the article is to highlight the importance of multiple funding flows to health facilities and present a conceptual framework to guide their analysis. The framework hypothesizes that when healthcare providers receive multiple funding flows, they may find certain funding flows more favourable than others based on how these funding flows compare to each other on a range of attributes. This creates a set of incentives, and consequently, healthcare providers may alter their behaviour in three ways: resource shifting, service shifting and cost shifting. We describe these behaviours and how they may affect health system objectives. Our analysis underlines the need to align the incentives generated by multiple funding flows. To achieve this, we propose three policy strategies that relate to the governance of healthcare purchasing: reducing the fragmentation of health financing arrangements to decrease the number of multiple purchaser arrangements and funding flows; harmonizing signals from multiple funding flows; and constraining providers from responding to undesirable incentives.
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Atención a la Salud , Financiación de la Atención de la Salud , Programas de Gobierno , Personal de Salud , Servicios de Salud , HumanosRESUMEN
Background: Informal payments limit equitable access to healthcare. Despite being a common phenomenon, there is a need for an in-depth analysis of informal charging practices in the Sub-Saharan Africa (SSA) context. We conducted a systematic literature review to synthesize existing evidence on the prevalence, characteristics, associated factors, and impact of informal payments in SSA. Methods: We searched for literature on PubMed, African Index Medicus, Directory of Open Access Journals, and Google Scholar databases and relevant organizational websites. We included empirical studies on informal payments conducted in SSA regardless of the study design and year of publication and excluded reviews, editorials, and conference presentations. Framework analysis was conducted, and the review findings were synthesized. Results: A total of 1700 articles were retrieved, of which 23 were included in the review. Several studies ranging from large-scale nationally representative surveys to in-depth qualitative studies have shown that informal payments are prevalent in SSA regardless of the health service, facility level, and sector. Informal payments were initiated mostly by health workers compared to patients and they were largely made in cash rather than in kind. Patients made informal payments to access services, skip queues, receive higher quality of care, and express gratitude. The poor and people who were unaware of service charges, were more likely to pay informally. Supply-side factors associated with informal payments included low and irregular health worker salaries, weak accountability mechanisms, and perceptions of widespread corruption in the public sector. Informal payments limited access especially among the poor and the inability to pay was associated with delayed or forgone care and provision of lower-quality care. Conclusions: Addressing informal payments in SSA requires a multifaceted approach. Potential strategies include enhancing patient awareness of service fees, revisiting health worker incentives, strengthening accountability mechanisms, and increasing government spending on health.
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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.
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Programas de Gobierno , Reforma de la Atención de Salud , Equidad en Salud , Financiación de la Atención de la Salud , Programas Nacionales de Salud , Cobertura Universal del Seguro de Salud , Gobierno Federal , Administración Financiera , Gastos en Salud , Instituciones de Salud , Humanos , Seguro de Salud , Kenia , Gobierno Local , Asistencia Médica , Calidad de la Atención de SaludRESUMEN
BACKGROUND: Through a number of healthcare reforms, Kenya has demonstrated its intention to extend financial risk protection and service coverage for poor and vulnerable groups. These reforms include the provision of free maternity services, user-fee removal in public primary health facilities and a health insurance subsidy programme (HISP) for the poor. However, the available evidence points to inequity and the likelihood that the poor will still be left behind with regards to financial risk protection and service coverage. This study examined the experiences of the poor with health financing reforms that target them. METHODS: We conducted a qualitative cross-sectional study in two purposively selected counties in Kenya. We collected data through focus group discussions (n = 8) and in-depth interviews (n = 30) with people in the lowest wealth quintile residing in the health and demographic surveillance systems, and HISP beneficiaries. We analyzed the data using a framework approach focusing on four healthcare access dimensions; geographical accessibility, affordability, availability, and acceptability. RESULTS: Health financing reforms reduced financial barriers and improved access to health services for the poor in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that HISP beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among the poor. CONCLUSIONS: Pro-poor health financing reforms improved access to care for the poor to some extent. However, to enhance the effectiveness of pro-poor reforms and to ensure that the poor in Kenya benefit fully from them, there is a need to address barriers to healthcare seeking across all access dimensions.
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Reforma de la Atención de Salud , Gastos en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Financiación de la Atención de la Salud , Seguro de Salud/economía , Seguro de Salud/estadística & datos numéricos , Adulto , Estudios Transversales , Femenino , Grupos Focales , Instituciones de Salud/estadística & datos numéricos , Servicios de Salud/estadística & datos numéricos , Humanos , Kenia , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Poblaciones Vulnerables/estadística & datos numéricos , Adulto JovenRESUMEN
BACKGROUND: Health inequity has mainly been linked to differences in economic status, with the poor facing greater challenges accessing healthcare than the less poor. To extend financial coverage to the poor and vulnerable, Kenya has therefore implemented several pro-poor health policy reforms. However, other social determinants of health such as gender and disability also influence health status and access to care. This study employed an intersectional approach to explore how gender disability and poverty interact to influence how poor women in Kenya benefit from pro-poor financing policies that target them. METHODS: We applied a qualitative cross-sectional study approach in two purposively selected counties in Kenya. We collected data using in-depth interviews with women with disabilities living in poverty who were beneficiaries of the health insurance subsidy programme and those in the lowest wealth quintiles residing in the health and demographic surveillance system. We analyzed data using a thematic approach drawing from the study's conceptual framework. RESULTS: Women with disabilities living in poverty often opted to forgo seeking free healthcare services because of their roles as the primary household providers and caregivers. Due to limited mobility, they needed someone to accompany them to health facilities, leading to greater transport costs. The absence of someone to accompany them and unaffordability of the high transport costs, for example, made some women forgo seeking antenatal and skilled delivery services despite the existence of a free maternity programme. The layout and equipment at health facilities offering care under pro-poor health financing policies were disability-unfriendly. The latter in addition to negative healthcare worker attitudes towards women with disabilities discouraged them from seeking care. Negative stereotypes against women with disabilities in the society led to their exclusion from public participation forums thereby limiting their awareness about health services. CONCLUSIONS: Intersections of gender, poverty, and disability influenced the experiences of women with disabilities living in poverty with pro-poor health financing policies in Kenya. Addressing the healthcare access barriers they face could entail ensuring availability of disability-friendly health facilities and public transport systems, building cultural competence in health service delivery, and empowering them to engage in public participation.
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Personas con Discapacidad/legislación & jurisprudencia , Política de Salud , Accesibilidad a los Servicios de Salud/economía , Financiación de la Atención de la Salud , Adulto , Estudios Transversales , Composición Familiar , Femenino , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Humanos , Seguro de Salud/legislación & jurisprudencia , Kenia , Aceptación de la Atención de Salud/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Embarazo , Factores Sexuales , Factores Socioeconómicos , Adulto JovenRESUMEN
BACKGROUND: Healthcare priority setting research has focused at the macro (national) and micro (patient level), while there is a dearth of literature on meso-level (subnational/regional) priority setting practices. In this study, we aimed to describe and evaluate healthcare priority setting practices at the county level in Kenya. METHODS: We used a qualitative case study approach to examine the planning and budgeting processes in 2 counties in Kenya. We collected the data through in-depth interviews of senior managers, middle-level managers, frontline managers, and health partners (n = 23) and document reviews. We analyzed the data using a framework approach. FINDINGS: The planning and budgeting processes in both counties were characterized by misalignment and the dominance of informal considerations in decision making. When evaluated against consequential conditions, efficiency and equity considerations were not incorporated in the planning and budgeting processes. Stakeholders were more satisfied and understood the planning process compared with the budgeting process. There was a lack of shifting of priorities and unsatisfactory implementation of decisions. Against procedural conditions, the planning process was more inclusive and transparent and stakeholders were more empowered compared with the budgeting process. There was ineffective use of data, lack of provisions for appeal and revisions, and limited mechanisms for incorporating community values in the planning and budgeting. CONCLUSION: County governments can improve the planning and budgeting processes by aligning them, implementing a systematic priority setting process with explicit resource allocation criteria, and adhering to both consequential and procedural aspects of an ideal priority setting process.