Health Service Provision in Kenya: Assessing Facility Capacity, Costs of

Care, and Patient Perspectives

Dr Caroline Kisia

Action Africa Help - International

26th Nov. 2014

Presentation Outline

• Background to the Study

• Study Objectives

• Methodology

• Results

• Conclusions

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Background to the Study

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Background• Kenya’s new Constitution – citizens’ right to health

• Devolution of healthcare service provision to Counties

• Limited health care budgets

• Need for evidence to guide policymaking and resource allocation

• Multidimensionality of health system functions

• Comprehensive and detailed assessment of the healthcare system performance rarely occurs

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Overview of the ABCE Study• A collaborative project between Action Africa Help-

International (AAH-I) and the Institute for Health Metrics and Evaluation (IHME), an independent global health research center at the University of Washington, Seattle

• Launched in 2011

• Funded through the Disease Control Priorities Network (DCPN), a multiyear grant from the Bill & Melinda Gates Foundation

• To comprehensively estimate the costs and cost-effectiveness of a range of health interventions and delivery platforms

• A Multi-country Study allowing for comparisons

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Objectives of the Study

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Objectives of the ABCE Study• The ABCE project aimed to

answer the questions of :– What is the Cost of producing

health services?

– Who is Accessing these health services?

– What Bottlenecks exist to health service delivery expansion

– How Equitable is access to health care services?

– What Tools exist for real-time monitoring and tracking health sector growth?

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Methodology

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Study DesignSample design

•Stratified random sampling - nationally representative sample of health facilities

Step 1: Counties from which facilities were drawn were initially grouped into 27 and later into 16 unique categories based on their:

•Average malnutrition rates – low, middle and high

•Health expenditures – poor, middle and wealthy

•Population density - rural, semi-dense and dense

Nairobi and Mombasa were automatically included due to their size and relevance to Kenya’s health service provision

18 counties were selected through the county sampling frame

Step 2: Entailed sampling facilities from each selected county across the range of platforms i.e. channels identified as offering health services in Kenya.

254 facilities (excluding DHMTs) were randomly selected through the facility sampling frame

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Sampling strategy for facilities

Data Collection

• Primary data collection took place from April to November 2012

• Four main data collection mechanisms:1. Existing data

2. ABCE Facility Survey – over 2,600 data elements• District Health Management Teams (DHMTs) received a modified

version of the ABCE Facility Survey.

3. Clinical chart extractions of HIV-positive patients on ART

4. Patient Exit Interview Survey

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ABCE Facility Survey

• Primary data collection from a nationally representative sample of 254 facilities

• Collected data on a full range of indicatorso Inputs, finances, outputs, supply-

side constraints and bottlenecks, indicators for HIV care

• Randomly sampled a full range of facility typeso National and provincial hospitals,

district and sub-district hospitals, maternity homes, health centers, clinics, dispensaries, VCT centers, drug stores or pharmacies, and DHMTs

Clinical chart extraction• Extracted data on HIV-positive patients currently enrolled in ART

• Chart data included patient demographic information, ART initiation characteristics (e.g., CD4 cell count, WHO stage, drug regimen, referral points), and patient outcomes

Patient Exit Interview Survey

• Over 4,200 structured interviews were conducted with patients after they exited study facilities.

• Questions included • reasons for the facility visit,• satisfaction with services• expenses paid associated with

the facility visit, • For the ART sub-sample HIV-

specific indicators.

Results

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Facility capacity and service provision

Facility capacity and service provision

• Most facilities provided key health services

• Service was of varied quality

• Gaps were identified between reported and functional capacity to provide care depicting an urban-rural divide.

• Availability of recommended equipment and pharmaceuticals was moderately high, but varied within facility types.

• Facilities showed higher capacities for treating infectious diseases than non-communicable diseases.

• Non-medical staff and nurses composed a majority of personnel

• More urban facilities achieved staffing targets than rural ones.

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Facility capacity and service provisionGaps in reported and functional capacity for care

• Many facilities reported providing a given service, but then lacked the full capacity to provide that service (e.g., lacking functional equipment or stocking out of medications).

Service Facilities reporting capacity

Facilities with functional capacity

Antenatal care 89% 12%

General surgery services 58% 13%

Facility capacity and service provisionCapacity for disease-specific case management

Facility capacity and service provisionHuman resources for health: personnel composition

Facility production of health services

Facility production of health services

• ART patient volumes quickly increased at primary care facilities; other patient visits were more variable over time.

• Medical staff in most facilities experienced low patient volumes each day.

• Facilities showed capacity for larger patient volumes given observed resources.

• ART patient volumes could moderately increase given facility resources, especially for district and sub-district hospitals.

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Facility capacity and service provisionOutputs: average outpatient visits, by platform, 2007-2011

Facility capacity and service provisionOutputs: average inpatient visits, by platform, 2007-2011

Facility capacity and service provisionOutputs: average ART visits, by platform, 2007-2011

Efficiency and Cost of Care

Efficiency and Cost of Care• Efficiency scores across platforms showed wide heterogeneity,

particularly within the private sector ranging from below 20% to 100%.

• On average, efficiency of public health facilities increased along the levels of care, posting dispensaries at 46% and national and provincial hospitals at 75%.

• In terms of spending, personnel accounted for the vast majority of annual expenditures across facility types.

• On average, facility costs per patient varied markedly across facility types– cost per outpatient visit ranged from KShs 342 at public dispensaries to

KShs 2,825 at national and provincial hospitals.

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Efficiency and costs of careEfficiency scores across platforms, 2007-2011

Efficiency and costs of careEstimated potential for expanded service production, 2011

Patient perspectives

Patient Perspectives

• Most non-HIV patients had medical expenses, whereas few ART patients reported paying for care

• Most patients spent less than an hour traveling to facilities, whereas waiting times for care varied more

• Patients gave high ratings for facility providers and slightly lower ratings for facility-based qualities

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Non-HIV patient perspectivesPatient reports of expenses associated with facility visit, 2012

Percent of patients ‘very likely’ to return to this facility if needing health services in the future

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Conclusions

Conclusions

• This multidimensional assessment provides a unique perspective on health facility capacity, costs and quality of care.

• The study indicates that there is room to utilize existing capacity to expand healthcare service provision at a relatively low marginal cost.

• Further analyses on this front would provide helpful insights towards Kenya’s aspirations of universal health coverage.

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Acknowledgements

Acknowledgements

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• This study was made possible through the efforts of a number of institutions and individuals:– The Institute of Health Metrics and Evaluation/UoW – managing the

ABCE project grant and providing the technical team for the study– Bill & Melinda Gates Foundation for providing funding– The Ministry of Health, Kenya for supporting the study– The 24 Research Assistants who conducted the field work

• The co-authors of the abstract from:• AAH-I (Ms Ann Thuo), • AAH Kenya (Ms Caroline Jepchumba & Dr Githaiga Kamau)• IHME-Africa (Prof. Tom Achoki)

For further information,

below are our contacts

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FAWE House, Chania Avenue P.O. Box 76598 00508

Nairobi, KenyaMobile: +254 (0) 20 3007755/6

www.actionafricahelp.org