Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya

We used a qualitative research methodology to explore inductively, the implications of devolution for equity, through generation of rich data by seeking to understand what equity means for those involved with decision-making and ‘how’ equity can be improved [22, 23]. This methodology gives “due emphasis to the meanings, experiences, and views of all the participants” (p. 43 [22]), to develop possible explanations and theories surrounding the implications of devolution for equity at multiple levels [24].

We carried out interviews with 269 individuals and 14 focus group discussions with an additional 146 participants, between March 2015 – April 2016 (see Table 4 in McCollum et al. (2018) [8]). Fourteen national level key informants were selected purposively. National, county and some health worker level interviews were carried out by the first author in English (a non-Kenyan national, trained qualitative researcher). 120 county level decision-makers were interviewed across the ten diverse study counties. Counties were selected to include representation of a range of poverty levels, geographic settings, cultural and social demography and health service coverage levels within the country (see Table 3 [8]). County level decision-makers were purposively selected to include politicians involved with decision-making for health, county treasury staff involved with budget guidance, gender and children’s office representatives and technical decision makers for health including members of the county health management team. Interviews with 49 health workers from sub-county, health facility and community levels were carried out in three of the ten counties, selected to include counties which aligned with REACHOUT² consortium data collection and which included representation for urban, rural agrarian and rural pastoralist settings. 86 interviews with close-to-community (CTC) providers, their supervisors and community members and 14 focus group discussions were carried out with community members from two out of the three counties. This data was collected by Kenyan national researchers, trained in qualitative research as part of an ongoing REACHOUT CTC provider quality improvement study in two counties (urban and rural agrarian). We used topic guides to explore equity implications of health decisions made following priority-setting for health at county level following devolution. The topic guides were developed through an iterative process following informal discussions with national key informants, discussion between colleagues and a period of reflection and revision after data collection in one county to ensure questions elicited the responses sought.

National policies were felt to influence equity and most respondents across all levels described improved equity between counties thanks to the equalisation fund for the most marginalised counties and consideration of poverty level within the ‘equitable share’. Yet upon reflection, we find that the national government’s medical equipment deal appears at odds with the stated emphasis on UHC, with some county governments not having the needed infrastructure or appropriately skilled staff to operate high technology equipment.

“Instead of being given finances to come and budget they (county government) were forced to take some equipment, that’s what happened. You were to take equipment and you do not have the personnel who is able to run them and you were given. So they are lying all everywhere with no use… it’s not good by the way because like us we were given the CT scan machines and we have no personnel.” County Non-Health Respondent, Female46

Respondents identified that after devolution there was increased funding available at the county level for health within formerly marginalised remote counties. Many county level respondents described investment to increase availability of services, infrastructure and allocation of staff for all health facilities, including the most remote.

“I think under devolution, there is more equity, communities that were previously marginalized - I’m talking about Turkana, Mandera, Wajir, Garrisa, Moyale - are receiving unprecedented development, things that they never imagined they would get. There is also the equalization fund which is also meant for these historically marginalized areas which is helping them also.” National Respondent, Male10

Investment in hospitals was a common priority for all counties, with nine out of ten county governments having either rehabilitated, upgraded or built a new county hospital. A minority of national respondents felt that investment in the county hospital may not have been the leading priority in terms of need within the county, but because it was a visible and tangible area for investment it was felt to have become a political priority.

“You know when you go to a county, and you find that county leadership decides okay we want a nice gate to our county hospital, and then you walk into the county hospital and there are no drugs. Then probably the workers have not been paid. What does that say? It’s because the, the leader wants to say ‘you see we know our hospital is shining’. So it may not necessarily be speaking to the needs.” National Respondent, Male07

In many cases expansion of infrastructure appears to have been entirely appropriate, particularly in formerly marginalised areas where there was a huge deficit and extremely limited geographic access to services. Many counties described investing in infrastructure for primary care, such as dispensaries and health centres which typically benefit poor populations more than rich. With county governments using their local knowledge of underserved areas to make more informed decisions regarding the location of new facilities.

Changing power structures since devolution were felt to have led to increased power held by politicians, rather than technical decision makers and health workers within the county. One of the challenges of this is the emphasis on visible curative services, rather than the less tangible (but essential) preventive services. Powerful political leaders were felt to accumulate more services, compared with less powerful leaders, regardless of need. Technical county level respondents at times felt that this had a negative impact on the level of equity within the county.

In many counties there were concerns raised, primarily by technical health decision-makers, that many of the health facilities constructed with the intention of improving availability of health services had not yet been staffed, equipped or added to the register to receive government drugs, supplies and funding. As a result, they remained non-functional and unable to provide effective health services to the population they were intended to benefit. A further threat looming, was seen to be the lack of future planning for these new facilities, with many health workers and health technical decision-makers across the counties highlighting that politicians and community simply do not appreciate the recurrent and maintenance costs needed for a health facility, potentially impeding functionality or quality of services provided and undermining future sustainability.

Community health services were widely acknowledged to expand availability, accessibility, acceptability and contact coverage of services and to perform a vital function in the quest for UHC (see acceptability and contact coverage sections). In around half of counties studied, there has been expansion in the availability of community health services since devolution. Whether community health was prioritised (or not) was felt to be related to the level of understanding about community health and political preference [8]. However, even where community units had been established there were, at times, coverage gaps. Respondents from one nomadic county in Northern Kenya, identified that prior to devolution CHVs had been identified during a community meeting held in the main town, with assumptions that each catchment village would have sent a representative. However, due to distance and inadequate mobilisation there were few attendees from the more remote catchment populations, with the result that CHVs were recruited predominantly from the main town. In order to ensure coverage of community health services in all villages, the county team were now returning to repeat the process. Respondents described innovation through recruitment of CHVs from within nomadic communities, who would therefore move with their community, even across country land borders.

“So today you will find this group living in Kenya, tomorrow they have crossed the border to Uganda…, but you know you cannot find facility, health facility remains home. So we make sure that we get CHVs from those communities, so they move with these communities.” County Health Respondent, Male39

Lack of variation in the number of CHVs for low density areas or hilly terrain created challenges for the CHVs, particularly those in pastoralist and some agrarian counties, with some CHVs having to travel up to 20 km between homesteads. As a result, CHVs and community members agreed that CHVs did not visit homes which were far away as frequently as homes close to their own, due to the long distance and lack of transport. Respondents from two counties described having introduced a modified community health structure, which accommodated varied population densities and terrain to address these challenges.

In addition to county government efforts to promote availability of services, national government have introduced several policies to increase access to services by increasing affordability of health services. These include the national policy for free maternal health care and removal of user fees from dispensaries and health centres, both introduced in 2013 shortly after introduction of devolution reforms, which was felt to have led to increased use of services:

“Following the free medical services; the work load has grown very, very high.” Health Worker, Male11

There were challenges with implementation of the free healthcare initiative however, due to lack of drugs available. This frequently resulted in patients who make contact with the health services still needing to pay in order to receive effective treatment, leading to the most poor remaining unable to receive effective care (see effective care section).

“Every area you go to, you are told drugs are not here [government health facility]. They prescribe and you go buy outside. This has made the cost of treatment higher and not affordable …Of course that tells you that only the people with resources will now be able to access services that are relevant. People who are wealthy will afford to pay in the private clinics. People who are poor will wait and seek alternatives, like going for traditional medicine or self-treatment, self-medication on the counter.” National Respondent, Male04

Improving geographic access to health services was described as an important priority for many counties (see availability section). The challenges of geographic access to health facilities were discussed in all counties, most extensively in those counties with nomadic populations. For those who lived far from the health facility (either in urban or rural areas) poor road infrastructure or seasonal weather changes created a barrier to accessing services. In these communities, outreach services formed a vital part of routine service delivery.

“The county they should be ready to fund for an outreach because some places … when it rains it’s like they have been cut off in terms of transport.” County Health Worker, Male03

Outreaches were identified by county, sub-county and health facility respondents as a means of improving health service coverage for the most remote communities, who did not have easy access to receive these services at a static health facility. The most widely described outreach services introduced since devolution, were the ‘beyond zero’ mobile clinics provided to each county by the First Lady’s Beyond Zero campaign to reduce maternal and neonatal mortality. These mobile clinics were felt to have contributed towards improved service access. However, there were still challenges surrounding their distribution, with all counties receiving one large bulky mobile clinic to achieve equality in distribution, regardless of level of need/ population size/ geography/ road terrain etc. As a result, people who live in the most remote and hard-to-reach areas remained unable to benefit, due to inadequate road infrastructure. Other forms of outreach services discussed included (donor) partner supported services, which typically remained unfunded by county governments following partner exit. Again, citizens living in the most remote areas remained unserved.

“We normally have integrated outreach … we expect the County government to be filling those gaps and it is not forth coming so we have a very big problem. So we can say there are totally no access.” Sub-County Respondent, Male04

Devolution provides counties with an opportunity to find new ways to stimulate demand for health services, e.g. through CHVs promoting use of health services, and to address barriers to the acceptability of services for patients with unique needs, e.g. deaf patients. This has at times been neglected, with a national member of the community health and development unit reporting that only half of counties have invested county government funds in community health services. Despite these planning deficits, CHVs (where present) were commonly described by facility and community level respondents as playing a key role in increasing acceptability and use of services.

“The community is well mobilized … and you can see the number of deliveries has gone up. Our people don’t like coming to the hospital to deliver, but because this CHV is impacting, now they are able to come to the facility.” County Health Respondent, Female40

In many counties, respondents described ensuring that a ramp is available at any new health facility which is being constructed, to ensure access for wheelchair users who reach the health facility (although reaching the health facility was recognised as a challenge for people with disabilities). Respondents from a few counties identified that CHVs were an important means of identifying and assisting people with disabilities and ensuring their linkage to support services.

“They [CHVs] are able to reach out to them, in fact we are able to get some out especially the disabled, the children with disability that used to be hidden, and nowadays we can see them being brought forward.” Sub-County Respondent, Female10

Having health workers trained in sign language at primary health facilities was an identified gap. Two counties had started or were planning to train health workers in basic sign language, to improve access to services for deaf patients.

Many counties have invested in hospitals and ambulances in efforts to strengthen referral services, but we found limited evidence to suggest this increased equitable contact with services (particularly for non-maternal health-related emergencies). Patients still need to pay user fees for services provided at hospitals (excluding maternal health services). Although waiver schemes are in place in many counties, challenges with long delays in reimbursement and limited scope for the payment (covers hospital fees only, rather than transport and other opportunity costs) continue to create barriers to patients making contact to use these services. Referral costs varied between counties, with no consistent policy regarding payment for ambulance referral. In one county, ambulance services were available free of charge for maternal health related emergencies. However, any other emergency could not use the ambulance, as a result of which the patient and their family would be obliged to seek private transport to reach a hospital. The major hospitals which offered a breadth of services and more experienced health workers were typically centred in urban areas, rather than the more remote places. Those living in more remote areas, who were poor were felt to experience a double challenge in reaching secondary level care.

By contrast to the challenges experienced by the most poor or those living in remote places with accessing level three services provided at the hospital, community members generally felt that community health volunteers (CHVs) (where present) improve contact with health services at the household level and prioritise attending the homes of those who are ‘vulnerable’. CHVs were often described by community members and their supervisors as providing additional support for their most vulnerable neighbours out of their own pockets.

There was limited emphasis on building the quality of health services provided following devolution. A range of respondents highlighted the inequitable dual level system for health (which pre-dates devolution). Under this system those who are rich pay for quality private care and those who are poorer receive perceived lower quality government services. Health workers and community respondents raised concerns around the quality of services provided at government facilities as a result of lack of drugs and supplies, particularly following increased patient contact coverage with services since removal of user fees at dispensaries and health centres.

Other quality concerns include insufficient numbers of staff, who are overworked. This was felt to lead to poor staff attitude as a result of stress and demotivation; clinician error due to tiredness and lack of support; long patient waiting times, with health workers having to serve up to 200 patients per day without the needed resources and support, a prerequisite to providing quality services.

“I have a problem with the services the doctors give and I feel bad about it, because I came here one day and I was misdiagnosed. The quality of services in this health centre should be upgraded.” Male community FGD04

Devolution has brought improvements for the supply side, by expanding the availability and geographic accessibility of health services across many counties. These improvements have been undermined to some extent by heavy investment in improving the availability of hospital services, which predominantly benefit the rich [25], compared with community health services, which promote access to services among those considered marginalised [26]. In addition, insufficient emphasis to ensure that the required human resources and drugs and commodities accompany infrastructure, hinders the quality of these services. The medical equipment deal appears to be at odds with devolution, which specifies that county governments are responsible for the provision of services from level one to level three (and which therefore includes decisions about procurement (or not) of diagnostic equipment for use within county referral hospitals at level three) [27]. It is also working against the recommendations for UHC, which ought first to prioritise those high priority services which are of benefit to all citizens, before contemplating low priority ones, which benefit a smaller minority of citizens [16]. In the push to address geographic access, many counties have sought to build new health facilities and extend curative services, but public health and population measures such as promotive, preventive and rehabilitative services at community level, which are all necessary for universal health coverage have been neglected to varying degrees [15, 16]. This has previously been described in Indonesia, where public health services reportedly deteriorated following devolution, with reduced access among poorer populations [28, 29].

Investment in infrastructure and equipment have been focused across both primary health facilities and hospitals. While primary health care has previously been demonstrated to be pro-poor, public hospitals in Kenya have primarily been used by the rich, with the richest quintile benefiting from two thirds of all hospital outpatient services [25]. Hospitals can quickly absorb vast amounts of money. In Kenya they have previously consumed 50% of the health budget [25]. It is therefore crucial that hospital construction and refurbishment which will primarily benefit the rich, does not undermine community-based primary health care services which can benefit all. Emphasis on infrastructure over quality, as perceived by users, was previously demonstrated following decentralisation in Tanzania and Indonesia [30, 31]. There local leadership were poorly informed about health, lacking the understanding to recognise the benefits of public health services [31].

The combined effect of devolution and abolishing of user fees have implications for equity in maternal health care, where demand has increased, but quality has not and neither has awareness of entitlement. This creates a tension in different country contexts. Our findings reveal that removal of user fees increased use of health services, in keeping with previous study in Kenya [32]. Gitobu et al. (2018) revealed that the number of deliveries in health facilities increased by 29.5% following implementation of the free maternal health services policy remaining consistent over the two year period following introduction of the policy [32]. In keeping with findings from our study, Gitobu et al. (2018) highlighted concerns about diversion of the free maternal health care funds by county governments, with implications for the quality of services [32].

Continued user fees (for non- maternal health services) at hospitals, with lengthy waiver process which did not cover opportunity costs was felt to contribute towards the continued exclusion of the most poor from receiving these services. Frequent supply chain gaps meant that health service users (who should receive free services) still needed to buy drugs elsewhere as described previously in Kenya, following introduction of devolution reforms [33, 34], resulting in continued exclusion of the most poor from effective services. Although recent study has indicated that when counties managed to procure drugs, health facilities reported a better order fill-rate, compared with prior to devolution [35]. The introduction of these policies at the same time as devolution has previously been recognised to have influenced their implementation, leading to compromised quality by operational challenges including delayed reimbursements at health facilities and exacerbation of existing weakness, including shortages of health workers and drugs and supplies [33]. There have been many discussions about increasing enrolment in national health insurance fund (NHIF) in Kenya, as a pathway to improving access to health services. As a result the Kenyan government have extended the service package to include outpatient as well as inpatient services, and have introduced an NHIF subsidy programme to identify and provide subsidy for NHIF membership for the poorest households [13]. However, as our study highlights, in order for patients to receive effective health services, any intervention to increase insurance coverage, must have a strong quality emphasis, to ensure that services covered under NHIF enrolment are of good quality and provide effective coverage.

In order to attain universal health coverage, services must also be acceptable to the population if they are to be utilised. Demand-side barriers including cultural and religious barriers, decision-making and gender autonomy and access to knowledge and information about health and services must first be addressed and overcome if health services are to be used [36]. Similar to other countries, devolved counties in Kenya have generally been slow to approach these barriers [37]. As we have published elsewhere, a few counties in Kenya have introduced demand generation strategies, such as community health approaches to encourage appropriate use of health services. However, most counties have not yet addressed constraints to accessing services, such as the acceptability of skilled delivery through engaging with cultural and religious beliefs and different community perceptions of health workers [38]. Community health approaches can address and reduce many of these barriers [26], alleviating and reducing the forces which reinforce exclusion and thereby helping to improve acceptability and use of services. When CHWs are adequately empowered there is opportunity for them to act as community advocates [39], playing a key interface role in mediating demand side factors for equity and responding to the unique opportunities afforded them as a consequence of their intermediary position between the health system and the community [40].

Quality was rarely described as a value for priority-setting and infrequently described as a priority which counties were seeking to address. Instead, quality gaps such as limited functionality of community health services, lack of consistent drug supply chain (in some counties), lack of funds to support supervisors were described. As a result of the perceived lack of quality at public health facilities a ‘rich-poor’ divide was evident. While this is not a new phenomenon since devolution in Kenya, county governments have so far demonstrated little commitment to improving the quality of health services at public health facilities. In fact some of the interventions introduced prior to devolution to promote quality, such as transferring funds directly from the national treasury to health facility bank accounts [25], have potentially been undermined as a result of the control of funds at county treasury level, leading to delayed and lower transfers to health facility bank accounts. If not addressed, this may lead to a widening divide between rich and poor patients, as occurred in Indonesia with rich patients attending private health facilities and poor patients attending public health facilities, where the service quality was perceived to be poor [29]. Quality improvement need not be costly, rather approaches which empower local solutions to quality through dialogue, rewarding best practice and advocacy can bring quality improvements with a modest resource investment [41]. With regards to community health services, supervision and the policy environment can affect the quality of community health services provided [42].

Application of the Tanahashi model to analyse equity changes following devolution provided scope to consider the various aspects of coverage (availability, accessibility, acceptability, first contact, effective coverage) and to identify potential bottleneck areas which can impede effective coverage [19]. It also allows space to identify groups with unmet needs [43]. Our findings are in keeping with work by Frenz and Vega, which highlights the interaction between supply and demand at various levels and the need for concern for groups with greater needs (see Fig. 1). This framework highlights how health and social policy, can influence the characteristics of the health system and the degree of vulnerability, livelihoods, empowerment and recognition of need for health services, within the population [43]. Dramatic reforms such as devolution have the potential to create seismic change, through revision of sub-national priorities for health and social policy and implementation. We find that county governments are taking many positive actions to expand the supply of services and characteristics of the health system, by removing some of the geographic and financial barriers to utilising services. There is, however, still need for a greater emphasis on improving the demand-side, by addressing and providing services which are acceptable to the population. Likewise, there is need for greater recognition of the needs of people who are most marginalised. Intersectoral collaboration seeks to address vulnerabilities, livelihoods, empowerment and recognition of the need for services among communities experiencing greatest needs, e.g. people living in the most remote areas. Several Latin American countries have employed intersectoral approaches to improve participation and the degree to which people with differing experience of power can benefit from and use health services [44]. These approaches have shown some degree of success, contributing towards improving population health outcomes and addressing equity [44]. Kenya’s devolved county governments have opportunity to invest in tailor made health care services, which include promotion and prevention measures that address the social determinants of health, perhaps learning from Brazil’s community-based family health programme. Other opportunities include the ability to identify marginalised groups in collaboration with other county departments and to plan actions which can both increase their access and use of health services, but also change their social determinants. Learning lessons from programmes such as the “Bolsa Familia” in Brazil, which seeks to create employment opportunities and income transfers for families in poverty, along with increasing access to public services will be strategic [44].

We find value in using the model as a framework to consider qualitative findings surrounding the process and content of priorities from an equity perspective following the introduction of devolution.