ruaraka uhai neema hospital

Documentation of a Cross-Subsidy Cost Recovery Model: Ruaraka Uhai Neema Hospital (RUNH) Case Study

Private Sector Innovation Programme for Health (PSP4H) Insert job reference

Prepared for Department for International Development (DFID)

June 2015

Documentation of a Cross-Subsidy Cost Recovery Model:

Ruaraka Uhai Neema Hospital (RUNH) Case Study Private Sector Innovation Programme for Health (PSP4H)

Documentation of a Cross-Subsidy Cost Recovery Model: Ruaraka Uhai Neema Hospital (RUNH) Case Study Private Sector Innovation Programme for Health (PSP4H)

June 2015 Cardno ii

Contact Information

Cardno Emerging Markets (UK) Ltd

Oxford House, Oxford Road

Thame

Oxon

UK

OX9 2AH

Telephone: +44 1844 216500

http://www.cardno.com/

Document Information

Prepared for Department for

International Development

(DFID)

Project Name Private Sector Innovation

Programme for Health

(PSP4H)

Date 30th June 2015

http://www.psp4h.com

Implemented by a Cardno Emerging Markets consortium:

With partners:

Funded by the UK Government:


June 2015 Cardno 3

Acronyms and Abbreviations

ANC Antenatal Care

ANOVA Analysis of Variance

CBOs Church Based Organization

CCC Comprehensive Care Center

CHV Community Health Volunteers

CHW Community Health Worker

CWC Child Welfare Clinic

DCA Direct Casualty

DLA Direct Laboratory

DPH Direct Physiotherapy

DXU Direct X-ray

FGDs Focus Group Discussions

GOPC Gynecological Out-Patient Clinics

KIIs Key Informant Interviews

KNBS Kenya National Bureau of Statistics

MCH Maternal and Child Health

MVA Manual Vacuum Aspiration

NGOs Non-governmental Organizations

OPD Out Patient Department

PMTCT Prevention and Mother-to-Child Transmission

RUNH Ruaka Uhai Neema Hospital

VCT Voluntary Counseling and Testing


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Recommended Citation

Private Sector Innovation Programme for Health (PSP4H). June 2015. Documentation of a Cross-

Subsidy Cost Recovery Model. Nairobi. PSP4H.


June 2015 Cardno 5

Foreword

The Private Sector Innovation Programme for Health (PSP4H) is a three-year DFID funded action research

program implemented by Cardno Emerging Markets and Consortium partners. The overall objective of the

PSP4H program is to learn and document lessons on how a market systems approach might benefit pro-poor

health interventions. PSP4H partnered with Ruaraka Uhai Neema Hospital (RUNH) which is managed by Amid

del Mondo-World Friends Onlus to document a case study on their existing cross-subsidy cost recovery model

with a focus on maternal and child health services. The Hospital’s mission is to promote access to affordable

and quality preventive, diagnostic and care services to the population of the informal settlements of Nairobi

North-East. The main distinction with other NGO health facilities is that it targets an 85% (minimum)

sustainability rate for its current expenditure with a multi-layer cross subsidy business model.

Specifically, the study sought to unravel the extent to which the facility actually services the poor population,

identify challenges and opportunities with the client referral system with special attention to clients from the

informal settlements, and recommend action points to improve this referral system.

The documentation took a retrospective survey of patient records from maternity and MCH departments at

RUNH, supplemented with key informant interviews with selected referral partners and focus group

discussions with clients. The cross-subsidy service delivery model is often considered to be a sustainable

innovation in health service delivery with the potential to serve the health needs of the poor. However, evidence

of cross-subsidization in the provision of healthcare remains largely anecdotal; this case study attempts to

review this model in action at RUNH in Nairobi, Kenya.

Almost two-thirds of maternity and maternal and child health (MCH) clients attended to at RUNH are

economically engaged. An analysis of revenue–price relationship indicates low price recovery for these two

services with the average revenue level for the maternity and MCH services being estimated at 78% and 72.4%

below the official prices respectively. A simple poverty screening tool has been developed for usage by RUNH

outpatient department to categorize the socio-economic and demographic characteristics of clients seen at the

health facility prospectively. This tool can be integrated with the hospitals' health information system.

A follow up analysis of cross-subsidy business modeling for other departments within the RUNH is needed to

better inform the financial sustainability of the model. PSP4H partnering with RUNH to document this case

study informs other low-cost health interventions the project is implementing, such as providing low-cost eye

care to low-income population in Nairobi by Nairobi Eye Hospital. We trust it will see broader application.

Ron Ashkin

Team Leader

PSP4H

Nairobi

June 2015


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Acknowledgement

PSP4H would like to acknowledge Dr. George Odwe, the consultant, and research assistant teams who

undertook the analysis and preparation of this report.

We are grateful for the support provided by the leadership and management of Amici del Mondo - World

Friends - Onlus (WF) team and Ruaraka Uhai Neema Hospital (RUNH) specifically Jacopo Rovarini and

Stefania Paracchini. Special thanks to the individuals, community members and partner organizations who

were contacted and interviewed during the preparation of this report. We acknowledge the contribution

provided by the PSP4H team - Ron Ashkin, Chris Masila, Pamela Godia, Rachel Gikanga, Mildred Kottonya,

Dorothy Mbuvi, Salome Wawire, Veronica Musembi, Ambrose Nyangao, Dolapo Olusanmokun, Daniel

Shikanda and Patricia Guchu. Finally, we thank DFID for their support to conduct this study enabling the

PSP4H Programme to provide a candid documentation and recommendations on cross subsidization for low-

cost healthcare services.


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Executive Summary

This study documents a cross-subsidy cost recovery model at Ruaraka Uhai Neema Hospital (RUNH). The

study goal was to determine the demographic and socio-economic profiles of maternity and maternal and child

health (MCH) clients attending RUNH over the past 36 months. The study also documents challenges and

opportunities within the client referral system with special attention to clients referred by RUNH partners.

Methods

The study adopted a retrospective survey of patient records from maternity and MCH departments,

supplemented with Key Informant Interviews with selected partners and Focus Group Discussions with

community members. The review was restricted to clients attended to at the health facility over the previous

36 months between January 2012 and January 2015. A total of 456 and 396 records were sampled from

maternity and MCH departments respectively. Eight key informants were conducted with representatives of

sampled partners. A total of three focus group discussions were held with community members mainly

pregnant and lactating mothers drawn from Zimmerman, Korogocho and Mathare informal settlements.

Findings

Ruaraka Uhai Neema Hospital (RUNH) serves as both a referral facility as well as a primary provider for

maternity services for residence of Nairobi East region. During the period from 2012 to 2014, utilization of

hospital services changed significantly. The total number of deliveries increased by 30% from 2,573 in 2012

to 3,750 in 2014. The growth occurred for both normal and cesarean deliveries. The number of MCH clients

increased by 10% from 32,382 in 2012 to 35,636 in 2014 and peaked in 2013. The increase was mainly

attributed to the increase in the number of child welfare clinic (CWC) and prevention of mother-to-child

transmission (PMTCT) clients while the proportion attending gynecological clinic (GOPC) and new ante-natal

care (ANC) clients slightly declined.

The majority of maternity and MCH clients are aged 26-35 years (55%) with 40% having attained post-

secondary education, however, a significant number (38%) do not state their level of education. About 67%

are currently engaged in some economic activity, i.e. 34% self-employment/doing small scale businesses, 18%

working in sale/service/clerical jobs, 12% are professionals, 15% are unemployed and 6% students. In terms

of place of residence, the majority of Maternity and MCH clients come from Kasarani followed by Zimmerman,

Githuri, Kahawa West and Roysambu.

An analysis of revenue–price relationship indicates low price recovery for maternity and MCH services. The

average revenue level for the maternity and MCH services is estimated at 78% and 72.4% below the official

prices respectively.

Currently, RUNH has a well-structured referral system with its partners. The referral system outlines who will

be treated and under what circumstances. Most of the partners refer for services not provided by their facility

and in cases where the provider/facility cannot serve the particular patient with that services (e.g. due to

complications requiring higher level care and or lack of supplies. The referring partner screens needy patients

based on place of residence, occupation, and access to financial services. Key partners interviewed identified

a number of challenges affecting the functionality of the current referral system. The challenges identified

include;

> Lack of ambulatory services;

> Lack of funds to facilitate referrals;

> Delays in making referrals;

> Poor health seeking behavior;

> Loss of follow-up-to referred clients; and

> Delays of care at the referral facility.


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Recommendations

a. Referrals

> Strengthening local coordination structures.

> Expand partnerships particularly with Level 1 Government Health Facilities.

> Establish linkages with community structures such as CHW and CHVs.

> Expand on current outreach programmes to include other informal areas currently not covered.

> Address late/delayed treatment of referred clients at the referral facility.

> Conducting consultative meetings with partners providing health services to standardize referral

procedures including transportation of needy patients.

> Establish a monitoring and evaluation system for referrals to inform the improvement of counter-

referral procedures.

> Improve on data collection especially at the registration point to ensure all socio-economic data of

patients seeking health services at RUNH are captured.

> Improving institutional and community linkages by integrating community resource persons into

the health and referral system to mobilize communities and create more demand for services.

> Raise awareness of complications and danger signs of maternal and child health at the

community level.

> Explore locally available resources for emergency transport and communication.

b. Sustainability of cross-subsidy model

> Conduct cost-recovery analysis for all departments to establish financial sustainability of the

current cross-subsidy model.


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Table of Contents

Acronyms and Abbreviations 3

Recommended Citation 4

Foreword 5

Acknowledgement 6

Executive Summary 7

1 Introduction 11

2 Literature Review 13

3 RUNH Partners 16

4 Methodology 17

4.1 Study design 17

4.2 Quantitative data 17

4.3 Qualitative data 17

4.4 Sampling and Sample Size of Patient Records 17

4.5 Data Analysis 18

4.6 Ethical Issues 19

5 Results 20

5.1 Overall Attendance 20

5.2 Sustainability of the Cross-Subsidy Model 27

6 Discussion 34

7 Recommendations 35

8 References 36

9 Appendix 1: Partner Key Informant Interview Guide 37

10 Appendix 2: Focus Group Discussion Guide 39

11 Appendix 3: Poverty Screening Tool 41

Tables

Table 2-1 : A cross-subsidy classification framework ................................................................................. 13 Table 4-1 : Category of partners, name of facility, location and number of KII and FGDs ......................... 17 Table 5-1 : Overall Hospital attendance 2012-2014 .................................................................................... 20 Table 5-2 : Distribution of MCH clients by service ...................................................................................... 23 Table 5-3 : Percentage distribution of sampled maternity and MCH clients by selected background characteristics .................................................................................................................................................. 24 Table 5-4 : Distribution of sample maternity and MCH clients by level of education .................................. 24 Table 5-5 : Utilization of MCH and Maternity services by education and occupation ................................. 26 Table 5-6 : RUNH revenues from maternity clients ..................................................................................... 28


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Figures

Figure 3-1 : Type of organizations ................................................................................................................ 16 Figure 5-1 : Maternity attendance by year .................................................................................................... 21 Figure 5-2 : Number of maternity attendance per quarter ............................................................................ 21 Figure 5-3 : Quarterly average in the number of Hospital delivery by type of deliveries .............................. 22 Figure 5-4 : MCH attendance by Year .......................................................................................................... 22 Figure 5-5 : Number of MCH attendance per quarter ................................................................................... 23 Figure 5-6 : Trends in maternity and MCH attendance by level of education .............................................. 25 Figure 5-7 : Main occupation ........................................................................................................................ 25 Figure 5-8 : Trends in maternity and MCH attendance by occupation ......................................................... 26 Figure 5-9 : Number of sampled maternity and MCH client by residence .................................................... 27 Figure 5-10 : How maternity patients paid for services .................................................................................. 28


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1 Introduction

Ruaraka Uhai Neema Hospital (RUNH) is a not-for-profit, mother and child healthcare facility, made operational

in 2009 and managed by Amid del Mondo-World Friends Onlus (an International Non-Governmental

Organization (NGO). Its mission is to promote access to affordable and quality preventive, diagnostic and care

services to the population of the informal settlements of Nairobi North-East. At the same time, differently from

many other similar institutions in Kenya, it targets an 85% (minimum) sustainability rate for its current

expenditure. At present, it runs the following departments: Out-Patient Department (OPD), Radiology,

Laboratory, Voluntary Counselling and Testing (VCT) and Comprehensive Care Clinic (CCC), Maternal and

Child Health (MCH), Casualty, Physiotherapy, Maternity. The hospital serves 115,000 patients per year, with

approximately a quarter of them receiving free or subsidized services (according to the hospital’s mission, the

proportion should be higher though, at least 40%). Such a pro-poor stand is made sustainable by the

compliance with a precise cost-recovery strategy attached to a multilayer cross-subsidy mechanism.

First, departments deemed strategic on the basis of the institutional mission such as Maternity and MCH are

allowed to run into deficits in order to reach their targets - deficits that are compensated by surplus to be

generated by other departments such as Laboratory, Radiology, etc. Second, walk-in patients who

autonomously access the services and pay out of pocket (OOP) are charged full fees. These patients are

assumed to be middle- and lower-middle class. Full fees are defined by the service cost plus a mark-up, a

price structure that allows it to generate a certain surplus margin. The third option includes walk-in patients

who autonomously access the services and pay through insurances are charged augmented fees. These

patients are assumed to be middle- and upper-middle class. The three options above enable the hospital to

generate higher surplus margin.

The fourth option includes referred patients. Patients referred by the hospital’s outreach programs (Mobile

Clinics, school-based Health Education and Safe Motherhood Program, Community-Based Rehabilitation

Program) or by partners located and operating in informal settlements enjoy either free or subsidize services.

The hospital’s network includes CBOs, local and international NGOs, churches and congregations, youth

groups and healthcare facilities. The partners act as a "filter", assessing their own beneficiaries' ability to pay

health services who qualify for referrals. Two major types of partners exist;

a. Sponsor-able partners. These are partners who have dedicated funds to sponsor their patients who

are unable to pay for healthcare. RUNH therefore has a formal agreement to share the cost of caring

for such referrals in the form of discounted or subsidized fees. In few cases, the patients are required

to pay a symbolic copayment.

b. Partners unable to sponsor clients: Some other partners do not present the same financial

capability and hence do not sponsor the health care for any client. For such clients RUNH provides

medical care to the referred patients without charging any client. Losses incurred by subsidizing or

waiving fees for this category of patients are covered by the surplus generated through serving the

first two categories (walk-in out-of-pocket paying clients and insurance clients).

RUNH faces certain information and operational gaps concerning its most strategic department (which is the

Maternity), related to the extent of the success of the cost-recovery strategy as stated in the mission of the

Hospital. The maternity unit serves both the middle class and poor patients. The facility applies a differential

pricing model (cross-subsidy model) while keeping the full fees affordable compared to the market rates.

Through this approach, the maternity unit has maintained a very high Bed Occupancy Rate (BOR) ranging

between 85% and 105% on a monthly basis.

There is a knowledge gap with regards to the socio-economic status of clients seen at the facility and whether

the facility is attending to poor clients as expressed in the facility mission statement. The cross-subsidy model

is also not well documented; the hospital is not aware of whether the cross-subsidies are sustainable for

maternal health. It’s not clear whether the clients seen in the maternity are from the informal settlements.

The study examines the extent to which the RUNH promote access to affordable and quality maternal and

child health services to the population of the informal settlements of Nairobi North-East region. The study helps

understand the socio-economic background of walk-in clients based on existing poverty indicators and the

effectiveness of the referral system in meeting the needs of the target clients.


June 2015 Cardno 12

The data analysis of this study will also inform the design of a poverty index form that can be used by RUNH

outpatient department to categorize the socio-economic and demographic characteristics of clients seen at the

health facility prospectively. The form can be integrated with the hospitals' health information system to help

in assessing demographic, socio-economic segmentation and residence of all (walk-in and referred) maternal

and child health clients.

Objectives of the Study

The main purpose of this study is to document a cross-subsidy cost recovery model being implemented at

Ruaraka Uhai Neema Hospital (RUNH) with a focus on maternal and child health services.

The specific objectives of the study include;

i. To determine the extent to which the facility promotes access to affordable and quality

maternal and child health services to the population of the informal settlements of Nairobi

North-East region.

This will be achieved by examining the demographic and socio-economic

segmentation of maternity and MCH clients attended to at the facility within the past

36 months.

ii. To identify challenges and opportunities with the client referral channel with special attention

to clients from the informal settlements referred by RUNH partners.

iii. To assess the sustainability of the cross-subsidy model with regards to maternal health.

iv. To develop a poverty index tool to be used by RUNH in documentation of the socio-economic

status of clients seen at the hospital.

v. Make recommendations on how to improve the referral system and the pro-poor target clients.


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2 Literature Review

Cross-subsidization refers to ‘cost-transference' whereby some or all of the costs of one product are transferred

to another product (Fjell 2001). In cross-subsidy models, higher prices paid by high-income consumers are

used to pay for premium services to subsidize low-cost services rendered to the poor consumers. The principal

of cross-subsidization has been applied in many service industries such as health, transport and

telecommunication, water, etc. For example, some airlines cross-subsidized lower density traffic with profits

from higher-density traffic while in telecommunications, profits from long-distance services may be used to

subsidize local ones (Guy et al. 2011). In healthcare, cross-subsidy applies in cases of a number of unprofitable

services that must be provided for patients for two main reasons; mandatory services as may be required by

law such as emergency services and those based on commitments to improving community's health. The

experience of RUNH demonstrates the essential nature of the cross-subsidy in the economic operations of the

hospital. In an effort to meet the institutional mandate, the hospital currently allows its strategic department

such as maternity and MCH to operate at a loss that is in turn compensated by surplus generated from non-

strategic departments such as Laboratory and Radiology,

A cross-subsidy classification framework

According to Fjell 2001, cross-subsidization framework can be classified based on effects of competition and

type of motivation as illustrated in Table 1 (Fjell 2001). The framework divides cross-subsidies into four cases;

predatory and profit motivated, predatory and non-profit motivated, non-predatory and profit motivated, and

non-predatory and non-profit motivated. The Cross-Subsidy Cost Recovery Model at Ruaraka Uhai Neema

Hospital (RUNH) follows the second dimension- predatory and non-profit motivated as explained by (Fjell

2001). As noted earlier, the major inpatient maternity services generate a negative subsidy to the institution.

As a result, RUNH uses the revenues from other services to help cover the costs of services that do not

generate as much (or any) revenue. Through such a cross-subsidization approach, the hospital has been able

to maximize certain revenue sources to support a mix of clients and services that meets the hospital mission’s

objectives. The existence of potential cross-subsidies is an essential component of a successful cost-recovery

strategy. This study contributes to the understanding of maternity and MCH clientele as well as the

sustainability of the cross-subsidy model implemented by RUNH.

Table 2-1 : A cross-subsidy classification framework

Profit motivated Non-profit motivated

Predatory Predatory pricing (temporary low price) financed by a cost transfer/ current profits.

Positiv

e

Welfare

eff

ect

N

egative

Permanent low price with revenue below incremental cost, financed by cost transfer/current profits, e.g., large scale motive

Non-predatory Cost transfer with unaltered price in subsidized market resulting in increased gross margin

Ordinary investment financed by cost transfer/current profit

Concealing internal efficiency by transfer for cost exceeding revenues at market price, e.g., ‘quiet life' motive

Provision of universal service in non-profitable market (public policy motive)

Adopted from (Fjell 2001)

Cross-subsidies are often considered the principal mechanism through which hospitals provide services

regarded as unprofitable. The poor in low and middle-income countries have limited access to health services

due to limited purchasing power, residence in underserved areas and inadequate health literacy. This has

resulted in significant gaps in health care delivery among a population that has a proportionately large burden

of disease. The private sector plays a vital role in the provision of both healthcare delivery and healthcare

financing to bridge this gap (Bhattacharyya et al.). Cross-subsidy model is considered as one of the innovations


June 2015 Cardno 14

in health service delivery that have the potential to serve better the poor's health needs. However, evidence of

cross-subsidization in the provision of healthcare remains largely anecdotal, and its extent is not well

documented (Guy et al. 2011). There is also a need for a more rigorous evaluation to investigate the impact

and quality of the health services provided and to determine the effectiveness of existing cross-subsidy

strategies.

Case Studies

Some organizations have managed to succeed in providing affordable and sustainable services through a

cross-subsidization strategy. They have been able to maintain quality services to sustainable levels through

cross-subsidy approaches of pricing their products and services. A common strategy is to exploit the greater

willingness and ability to pay amongst the wealthier patients to cross-subsidize expensive services for lower-

income patients.

LifeSpring Hospital has excelled in offering high quality maternal health care at affordable rates for India’s low

income population (IIPS, 2007). Its core customer base is the bottom 60% of the Indian population income

segments, who have a household income of Rs 3,000 to Rs 7,000 per month (approximately USD 2-5

USD/day). A for-profit organization - although not profit-maximising, the hospital adopted an innovative private

model which has enabled it to maintain its low costs services at the same time providing high quality service.

Lifespring model is premised on four strategies; Service specialization, maintaining low costs is its low-capital

expenditure model, innovative structuring of partnerships and effective marketing. At the beginning, LifeSpring

followed a cross-subsidy model, whereby customers in the semi-private and private wards would subsidise

customers in the general ward. This allowed the hospital to meet its financial and social goals

Aravind Eye Care Hospital, one of the largest eye care provider in the world has managed to attract wealthier

patients who pay market rates and then provide the same services for the poorer who constitute about 70% of

their patients at a highly subsidized rate or for free (Aravind Eye Care System 2011). Aravind Eye Care Hospital

established differential pricing by the patients’ choice of amenities and the type of lens to be inserted in the

eye, not by the quality of treatment the patient gets. All patients - regardless of ability to pay - receive the same

medical care, but paying patients can choose soft lenses and sleep in private rooms, while non-paying patients

are given the basic hard lens and sleep in open dormitories on mats. This approach, called quality targeting,

is an efficient way of assessing financial need because those who can afford private rooms and soft lenses

are much more likely to choose them.

Another example is 1298 Ziqitza Health Care Limited, which provides private ambulance services using a

tiered fee system (Ziqitza Health Care Limited 2012). Patients call the ambulance service and are charged

according to the hospital they have arranged to be transported to - those going to private hospitals are charged

above cost, those going to free government hospitals pay a nominal fee and trauma patients do not pay. In

this strategy, a patient's ability to pay is gauged from the choice of hospital. The patients have an incentive to

represent their ability to pay because it impacts the quality of hospital care they receive subsequently.

Approximately 20% of patients carried by the ambulance service over the last three years were subsidized,

allowing Ziqitza to be financially sustainable.

Another system of cross-subsidy that is slightly different from the ones described above involves encouraging

healthcare providers to offer subsidized services to poor people. For example, Dentista Do Bem, a large

network of private, for-profit dentists in Brazil provides free dentist services to poor patients every day

(Bhattacharyya et al.). It is a form of charity that has a limited impact on the earnings of for-profit providers,

with paying customers indirectly "subsidizing" the cost of caring for poor patients within a given practice.

Challenges associated with cross-subsidization

Arguments against the use of cross-subsidies model in the provision of healthcare to the low-income persons

are based purely on economics (Paolucci, 2011). The presence of externalities in utilization of healthcare

services, individuals’ risk of becoming bad risks and the moral hazard effects induced by cross-subsidization

are some of the reasons why some governments or organizations discourage enforcing system of cross-

subsidies. Externalities that can either be positive or negative develops when spending of a person affects the

utility functions of another individual. Utilization of a particular health care service can produce an external

effect if some consumers are willing to pay for its consumption by others. Positive (negative) externalities occur

when actions of one set of individuals make other individuals better (worse) off, yet the first set neither bear

the costs nor receive the benefits of doing so.


June 2015 Cardno 15

On the other hand, moral hazard is caused by adverse behaviors encouraged by the guarantee of financial

protection (subsidies) against losses caused by the occurrence of adverse events (Gruber, 2005). In other

words, a cross-subsidization may send the wrong signals to the consumers. These signals translate into

inefficient choices by users at both ends of the tariff scale. On the one hand, it may lead to over-consumption

of a good and services that are offered free of charge at marginal cost while on the other hand, incentives may

cause organizations to focus more on the relatively wealthy segment of the market.


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3 RUNH Partners

To meet the demands of maternal and child health services, RUNH collaborates and works in partnership with

healthcare facilities programs and organizations. These partnerships support effective linkages and referrals

between the Maternal and Child Health Service and other services and enable the provision of cohesive service

delivery when more than one service is involved. Working in partnership with other organizations and services

providers is particularly important when providing a service for the vulnerable populations especially the poor.

The following section presents the profile of collaborating partners. Most of the collaborations are with Faith-

based organizations (FBOs) and health facilities as shown in Figure 3-1. The majority of these organizations

(76%) have documented partnership agreement with RUNH. These figures are based on a list of 41 partners

as provided in the partner roster. Out of the 41 partners, RUNH collaborates with only one public health facility

(Korogoch Health Center). Currently, RUNH has an agreement to offer free maternity services to clients

referred by five clinics located in the slums: Baraka Health Center in Mathare area, Provide International

located in Korogocho and Dandora, Tumaini Clinic in Korogocho, NCCK Huruma Clinic in Huruma area and

Redeemed Gospel Church in Baba Dogo.

Figure 3-1 : Type of organizations

37%

37%

19%

7%Faith-BasedOrganizations

Health facility

NGOs / CBOs

Others


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4 Methodology

4.1 Study design

The study used both quantitative and qualitative research strategies. Specifically, the study was based on a

retrospective survey of patient records from Ruaraka Uhai Neema Hospital, supplemented with Key Informant

Interviews (KII) and Focus Group Discussions (FGDs) with selected referral partners.

4.2 Quantitative data

Quantitative data was obtained from a review of patients' records at MCH and the maternity department. The

review was restricted to patients seen in the past 36 months between January 2012 and January 2015. Each

patient demographics (age, sex, marital status), socio-economic data for all hospitalizations during the study

period were obtained. Analysis of sustainability was based on patients records extracted from the new

database system for the periods September 16, 2014 up to May 29, 2015.

4.3 Qualitative data

Key Informant Interviews (KIIs) were conducted with partners mainly involved in referrals in selected facilities.

The KII included hospital administrators, clinicians, nurses, and CHWs purposely selected from the list of

partners. The interviews explored referral processes and procedures in the facilities, referral data collection

and use, challenges in the referral system and recommendations for improving the referral system. A total of

8 KIIs were conducted.

The study also held Focus Group Discussions (FGDs) with community members who were likely to use

Maternity and MCH services. The FGDs comprised 8–12 participants, including women 15-49 years who were

either pregnant or lactating. The participants were purposely selected from the community with the help of

Community Health Extension Workers (CHEWS). FGDs explored factors considered for the choice of facility

and the understanding of quality and affordable care. Also, previous reports produced by RUNH were

reviewed. Table 4-1 below lists category of partners, name of health facilities, location, number of KII and

FGDs conducted.

Table 4-1 : Category of Partners, Name of Facility, Location and Number of KII and FGDs

Category of Partner Name of facility Location Number of KII/FGDs

KII Faith –Based Organizations

Missionaries of Charity Frs Pangani 2

St. John School Korokocho 1

NGOs Alice for Children (INGO) Korogocho, 1

St. Kizito Vocational Training Institute Roysambu 1

Private Healthcare Facilities

Baraka Health Centre Mathare 2

Redeemed Gospel Health Centre

Baba Dogo 1

FGDs Pregnant and Lactating Mothers

Zimmerman 1

Korogocho 1

Mathare 1

4.4 Sampling and Sample Size of Patient Records

Sample patients' records were obtained from MCH and Maternity Departments. Only patients who received

services during the period January 1, 2012 and December 30, 2014 were sampled. The following formula was

used to determine the sample size,

n = c2Np (1-p)/ (A2N) + c2p (1-p)

Where,


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n = the sample size required; N = the whole target population in question; p = the average proportion of records

expected to meet the various criteria (1-p) is the average proportion of records not expected to meet the criteria.

In this study, 50 percent was used; A = the margin of error deemed to be acceptable (calculated as a

proportion) e.g. for 5% error either way A = 0.05 and c = a mathematical constant defined by the Confidence

Interval chosen i.e. (how sure we need to be of the result).

From the records available, over 10,000 patients had attended maternity services over the period under review.

MCH had more than double the number of maternity clients during the same period. Applying this as a sampling

frame a sample size of 370 and 450 for Maternity and MCH respectively was calculated. Slightly above the

calculated sample size (approximately 400 and 500 clients in each category) was sampled to increase chances

of getting those with most of the desired information.

Selection of the patient’s record

A simple random sampling strategy would be preferred to select records since it gives every patient within the

audit population an equal chance of selection. However, this was not practical as it was not possible to

generate a single list of electronic patients' record from which to allocate random numbers. Instead, a quasi-

random sampling also known as a systematic random sampling was used. To avoid biases, a sampling frame

based on the month the patient was first registered with the services was used rather than the one based on

names or File number of patient. In this regard, the sampling frame was derived from the patients' registers at

the Maternity and MCH departments. For example if the total sample size is 400, then we divide this by 36

months to get 12 patients per month (36 is derived from the period of analysis-January 1, 2012- December 30,

2014).

Based on the number of patients attending maternity department per month we divide that by 12, to obtain the

interval. For example if 270 patients obtained maternity services in the month January 2012, then we divide

270 by 12 to get 23. Therefore, we will sample every 23rd patient for that month. To ensure that every patient

in the population had an equal chance of being selected, the starting point was picked randomly. In the above

instance, the starting number must be between 1 and 23. This means that you could be auditing patients 1,

24, 47, 60, etc., or 2, 25, 48, 61, etc. The start point must be random because if you always started with the

first patient, the second patient would never have a chance of being selected.

Demographic and socioeconomic characteristics

The RUNH patient’s record forms have options for collecting information on demographic and socio-economic

characteristics of every patient that receives services at the hospital. An electronic replica of the patient’s

record form also exists. Some of the bio-data includes a patient number, name and date of birth, sex, age,

marital status, the number of children, number of dependents level of education, occupation and area of

residence. More often than not as we found out during data extraction, information on the key socio-economic

variable (education and occupation) was missing in the electronic form. This informed the use of manual patient

registry system.

Education and income data were each disaggregated into 4 and 7-level categorical variables respectively, to

ensure similar sample sizes across socioeconomic subgroups. Education level was categorized into, none,

primary, secondary and post-secondary. Occupation was categorized into; unemployed/housewife,

household/domestic, professional, self-employed/business, sales/service/cleric, students and others. Similar

aggregation levels for occupation and education have been used elsewhere and shown to be important

distribution of respondents (Kenya National Bureau of Statistics (KNBS) and ICF Macro 2010).

4.5 Data Analysis

For quantitative data, both univariate and bivariate data analysis methods were used. Specifically, the study

employed frequency and cross-tabulation analysis. Analysis of variance (ANOVA) was conducted to test

whether there was any significant different in the mean distribution of socioeconomic variables in the three

years under review i.e. 2012, 2013 and 2014. Qualitative data from the audio recordings from the FGDs were

transcribed verbatim into MS Word files. The analysis entailed open coding and progressive categorization of

issues using a combination of inductive and deductive approaches. Emerging categories subsequently were

modified and grouped into themes. Relationships and connections between the data coded were explored by

annotating them along the key items (codes) used for ordering the interview questions.


June 2015 Cardno 19

4.6 Ethical Issues

In this study anonymity of hospitals, health care providers and patients are of utmost importance. Several

measures were taken to ensure confidentiality of the collected information. Each record reviewed was given a

unique study number so that patients' identity would not be revealed. During the records review process, data

was directly entered into a protected electronic database. The record reviewer had a personal password for

the electronic database. Patients' names were not included in the database and after completion of the data

collection and analysis, medical record identifiers were destroyed.

The plan for this study was reviewed and approved by the management of Amici del Mondo - World Friends -

Onlus and Ruaraka Uhai Neema Hospital. Additional verbal approval was provided by Ruaraka Sub-County

health departments. In the facilities, informed consent was obtained from all participants before the

questionnaires were administered and the FGDs conducted. Approval to abstract referral data was obtained

from the facility in-charges, departmental in-charges of the maternity and MCH departments.


June 2015 Cardno 20

5 Results

5.1 Overall Attendance

Table 5-1 presents the number of patients who sought medical services by age, sex and type - that is whether

the patient was new or old. In 2014, RUNH was visited by a total of 98,363 patients of which 25.8 percent were

children age five years and below while 68.4 percent were over five years of age. From records reviewed, the

number of patients has slightly declined compared to the previous years. Interestingly, the proportion of new

patients was higher in 2014 than previous years. The proportion of patient seeking direct services such as

direct casualty-DCA, direct laboratory (DLA), direct physiotherapy (DPH) and direct X-ray (DXU) slightly

increased in 2014 compared to other years.

Table 5-1 : Overall Hospital attendance 2012-2014

2012 2013 2014

Age

Child (Under 5 years) 25.6 26.3 25.8

Over 5 years and adults 70.9 69.9 68.4

Unknown/not recorded 3.5 3.8 5.8

Sex

Female 64.1 65.0 62.6

Male 35.9 35.0 31.6

Unknown/not recorded 0.0 0.0 5.8

Type

New 33.7 30.0 38.3

Old 62.8 66.6 55.9

Direct Services & Medical Report 3.5 3.5 5.8

TOTAL 116324 118034 98363

Source: RUHN Patients Records

Maternity Attendance

In urban Kenya, many people struggle to access maternal and child health services due to low-quality

infrastructure, an ineffective emergency referral system and a lack of awareness about danger signs during

pregnancy. Affordable governmental run clinics are overcrowded while better private facilities are unaffordable

to many and do not engage the urban poor. Evidence of changes in the market for maternity services can be

traced to the experience of RUNH. The trend in the utilization maternity services is presented in Figure 5-1. In

general, the result reflects an increase in the number of women utilizing delivery services. The number of

clients delivering at the facility increased to 3,750, up from 2,573 in 2012, representing over 30 percent

increase in three years. Figure 5-2 shows the trend in quarterly maternity attendance. The number of maternity

attendance has been growing over time.


June 2015 Cardno 21

Figure 5-1 : Maternity attendance by year


Figure 5-2 : Number of maternity attendance per quarter

The health facilities records revealed that the hospital had provided services to many more maternity clients.

Of all the modes of delivery, normal deliveries were highest than the other types of deliveries (Figure 5-3). The

analysis shows that there has been an increase in the quarterly average of the number of maternity attendance.

The increase may be attributed to increase in the number of normal and caesarian deliveries. The analysis

shows an increase in average quarterly normal deliveries from a 201 in Jan-Feb 2012 to 280 in Jan-Feb, 2015.

Similarly, the number of caesarian deliveries increased over the same period. However, due to lack of

consistent data, it was not possible to compute the number of discharges over the period to gauge the intensity

of use of the hospital.

2.5

3.53.8

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June 2015 Cardno 22

Figure 5-3 : Quarterly average in the number of Hospital delivery by type of deliveries


MCH Attendance

To promote the health and survival of mothers and babies, RUNH offers the following services to its clients

(gynecology clinic, antenatal clinic, obstetric ultrasound, prevention-of-mother-to child-transmission of HIV

(PMTCT) and Child Welfare Clinic (CWC) (which includes postnatal care, child vaccination and pediatric clinic).

Figure 5-4 below highlights the trends in the number of clients attending MCH department. Overall, the number

of MCH clients increased over the period under review by over 10 percent from 32,382 in 2012 to 35,636 in

2014 and peaked in 2013 at 35815

Figure 5-4 : MCH attendance by Year


Figure 5-5 shows the trend in MCH clients' attendance per quarter. The result shows a growing number of

attendances at MCH department. Trends show attendances have been highest in the month of October to

December in 2012 and 2013. However, there was a decline in the number of MCH attendance from July 2014

to December 2014.

43

77

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281

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Ceaserian delivery Normal delivery Others Total

32.4

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2012 2013 2014

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June 2015 Cardno 23

Figure 5-5 : Number of MCH attendance per quarter


Table 5-2 presents the breakdown of MCH clients by type of services. The analysis shows variation in the

proportion of clients receiving MCH packages. While the data suggest an increase in the number of MCH

clients, the increase was mainly attributed to the increase in the number of Child Welfare Clinic (CWC) and

PMTCT clients. The proportion of patients attending gynecological clinic (GOPC) slightly declined. At the same

time, the proportion of old ANC clients remained unchanged, and that of new clients slightly declined. In 2012,

the hospital averaged 2,699 MCH clients per month and in 2013, that average had increased to 2,985. The

average monthly MCH client was 2,970 clients, suggesting an improvement in the numbers receiving antenatal

attention.

It should be emphasized that the above data only refers to the use of MCH services at RUNH. Clearly some

women may choose to deliver at the hospital and decide to seek antenatal care services from other sources,

however, there is little indication that this occurs sufficiently frequently to modify the above observations.

Conversely, it is not known whether the women deliver at the facility are the same women who attend ANC. It

is possible that some of the women who use RUNH antenatal services deliver in other settings. To the extent

that this occurs, the figures may overstate the amounts of antenatal care received by those who deliver in

RUHN.

Table 5-2 : Distribution of MCH clients by service

GOPC ANC New ANC Old PMTCT CWC Monthly Average

Total Number completed

4th ANC Visit

2012 20.1 6.9 20.0 5.8 47.3 2,699 32,382 -

2013 19.6 6.4 18.5 6.4 49.1 2,985 35,815 2374

2014 17.4 6.7 16.2 7.1 52.7 2,970 35,636 1252


Demographic and Socioeconomic Profile

0.0

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June 2015 Cardno 24

One of the key outputs of this study was to document demographic and socio-economic profiles of Maternity

and Child Health (MCH) clients. The following section presents the demographic and socioeconomic profiles

of sampled clients attending ANC and maternity services at RUHN. The demographic variables considered

include; age, marital status and parity (number of living children) while the socio-economic variables were;

occupation, education and residence. The analysis is based on a sample of 456 maternity and 396 MCH

records for the period January, 2012 to December, 2014.

Demographic Profile

Demographic characteristics of the sample are reported in Table 5-3. The majority of women attending

maternity and MCH services are aged 26-35 years (55%) followed by 16-25 years (35%). The oldest and

youngest age cohorts attending maternity and MCH services at RUNH accounted for only 8.3% and 1.4%

respectively. The average age for all women was 27.9 years. In terms of marital status, the majority of clients

are married (81%) while a significant proportion (19%) are single mothers. About one out of four women

seeking maternity or MCH are first-time mothers (24%) while the majority are of second parity.

Table 5-3 : Percentage distribution of sampled maternity and MCH clients by selected background characteristics

Characteristics Frequency (n=852) Percent

Age

<18 Year 12 1.4

19-25 Years 295 34.6

26-35 Years 468 54.9

36+ Years 71 8.3

Missing 6 0.7

Marital status

Single 160 18.8

Married 690 81.0

Widow 2 0.2

Number of children

Expecting 1st Child 208 24.4

1 374 43.9

2 178 20.9

3 or more 92 10.8

Source: RUNH ANC and Maternity data, 2012-2014

Socioeconomic Profile

Education

About four out of ten clients attending ANC or MCH have post-secondary education while 16% have a

secondary level of education. Only 5% of clients attending ANC or MCH clinic have a primary level of

education. Surprisingly, level of education for a large proportion of clients (39%) was missing either because

the patient did not state or it was not recorded by record clerk (Table 5-4).

Table 5-4 : Distribution of sample maternity and MCH clients by level of education

ANC Maternity Combined

Level of Education % Total % Total % Total

None 0.0 0 0.4 2 0.2 2

Primary 3.3 13 6.6 30 5.0 43

Secondary 15.2 60 16.0 73 15.6 133

Post-Secondary 50.0 198 31.8 145 40.3 343

Missing 31.6 125 45.2 206 38.8 331

Source: RUNH ANC and Maternity data

The level of education is often used as a proxy for poverty when direct measures such as income and

expenditure data are lacking. The same principle is used in this study by looking at any possible changes in

the level of education of clients who obtained services from maternity and MCH department during the period

under review. Results are presented in Figure 5-6. The analysis of variance (ANOVA) test did not yield any

significant variation in the average number of patients each year by the level of education. However, a high


June 2015 Cardno 25

number of women with post-secondary education attending maternity or MCH services may act as a pointer

to increase in the number of economically better off women accessing the services.

Figure 5-6 : Trends in maternity and MCH attendance by level of education


Occupation

The majority of the clients attending ANC or MNCH clinic (about 67%) were currently engaged in economic

activity. The main occupation was self-employment/small scale businesses (34%) followed by working in

sale/service/clerical jobs (18%). The proportion of ANC or maternity clients working as professionals was about

12%. The analysis shows that a significant proportion of ANC or maternity clients were unemployed (15%)

while 6% were students (Figure 5-7).

Figure 5-7 : Main occupation


Figure 5-8 presents trends Maternity and MCH attendance by occupation. Results show a slight increase

among women who are self-employed/business and among employed in sales/service/clerical jobs. However,

there was a 5% drop among clients working as professionals.

0.0

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2012

2013

2014

15%

6%

34%18%

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3% 12%Unemployed/Housewife

Students

Self-employed/doing Business

Sales/Services/Clerk

Professionals

Others

Missing


June 2015 Cardno 26

Figure 5-8 : Trends in maternity and MCH attendance by occupation


Utilization of MCH and Maternity services by education and occupation

The analysis was done on the relationship between education and occupation to validate the findings. The

result shows successful matching of the level of education and type of occupation of 488 MCH and Maternity

clients. A simple chi-square test was conducted to test whether there was a significant relationship between

the level of education of ANC and Maternity clients and the type of occupation engaged in. Theoretically, it is

expected that high-level of education will generate the highest returns. Evidence shows that highly educated

individuals have greater cognitive and social survival skills, such as problem-solving, teamwork, structure,

routine, and dependability (Heras-Muney 2005).

The finding shows a significant association between level of education and type of occupation. Professional

clients i.e. teachers, accountants, etc., were more likely (92%) to have post-secondary education (Table 5-5).

These findings authenticate the study data source.

Table 5-5 : Utilization of MCH and Maternity services by education and occupation

No Education Primary Secondary Post-Secondary

Total

Unemployed/Housewife 1(1.3) 12(15.8) 28(36.8) 35(46.1) 76

Students 0(0.0) 4(11.4) 4(11.4) 27(77.1) 35

Self-employed/doing Business 0(0.0) 13(6.9) 62(33.0) 113(60.1) 188

Sales/Services/Clerk 0(0.0) 6(6.3) 14(14.7) 75(78.9) 95

Professionals 0(0.0) 0(0.0) 6(8.0) 69(92.0) 75

Others 0(0.0) 3(15.8) 6(31.6) 10(52.6) 19

Total 1(0.2) 38(7.8) 120(24.6) 329(67.4) 488


Residence

Figure 5-9 presents the distribution of maternity and MCH clients by residence. The analysis is based on the

place with 10 or more clients. The majority of Maternity and MCH clients are from Kasarani followed by

Zimmerman, Githurai, Kahawa West and Roysambu in that order. It is important to note that most of these

areas have both middle class and informal settlement clients. These findings show that the hospital has been

able to successfully expand the geographical coverage of maternal and child healthcare services. The

expansion in geographical scope may be attributed to outreach activities, educational camps and community

network clinics (Summary medical camp reports, 2014).

15.9

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Unemployed/Housewife

Students

Self-employed/doing Business

Sales/Services/Clerk

Professionals

Others

Missing

Occupation

2014 2013 2012


June 2015 Cardno 27

Figure 5-9 : Number of sampled maternity and MCH client by residence

5.2 Sustainability of the Cross-Subsidy Model

Cost-Recovery Experience

The mission of RUNH is to provide quality, affordable and accessible healthcare services to the less privileged.

In line with this goal, RUNH implements a cost-recovery model that aims to remove economic barriers to health

care in a multilayer cross-subsidy mechanism as earlier explained in the introduction section. Under this

system, poor clients are allowed to enjoy either free or subsidized services. The hospital's network that includes

CBOs, local and international NGOs, churches and healthcare facilities evaluates the patient's ability to pay

before making referrals. Upon receiving such a patient, RUNH verifies the patient’s ability to pay and modifies

or waives the service charges accordingly. The following section attempts to evaluate the sustainability of this

model that has been in operation for over two years. The analysis is based on data from a new patient database

commissioned in September, 2014. As a result, the analysis was based on seven months period from

September 16, 2014 to May 29, 2015.

Maternity account analysis

Figure 5-10 shows how maternity patients paid for services between September 16, 2014 and May 29, 2015.

A total of 2,933 records of payments were available for analysis. The majority (73.4%) were walk-in patients

who paid out of pocket (cash), 12% patients paid through insurance or company and 15% of patients were

referrals. The referred patients qualified for subsidized or free maternity services.

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June 2015 Cardno 28

Figure 5-10 : How maternity patients paid for services

Revenue-Price Relationships

For some types of services, it is possible to establish a direct relationship between revenues and prices to

determine the proportion of exemption granted to the standard prices. RUNH offers a standard charge for the

use of maternity services. Revenues from in-patient (maternity) visits are accounted for separately from other

revenues. Since the number of maternity visits is also recorded, it is possible to determine the average revenue

per maternity visit and compare it to the "official" price. A similar analysis can be made for MCH services, which

also have a standard price and separately recorded revenues. The results are presented in Table 5-6.

Table 5-6 shows the data for RUNH Maternity Clients over the seven-month period. The analysis is based on

seven main services and takes into consideration the changes in maternity/gynecological charges effected in

January, 2015. We assume that paying patients eventually paid the full amount due. Among the services

evaluated, the average revenue for normal delivery, caesarian delivery, myomectomy, total abdominal

hysterectomy and MacDonald stitching were lower than their respective official prices; while the average

revenue for manual vacuum aspiration and laparotomy exceeded the official hospital price. The average

revenue level of the seven maternity services evaluated is estimated at 78% below the official prices. For

example, the average revenue for normal delivery over the seven-month period was Ksh.7,606.70 while the

official price was Ksh. 9,000 and Ksh.12,000 in 2014 and 2015 respectively. As a result, the price recovery

was 72.4%.

A similar experience is found in the MCH department. Analysis of the price-recovery percentage is lower for

ANC services - 87% (Tables 5-6). For ANC, data is based on new clients between September 16, 2014 and

May 29, 2015. The findings above show that RUNH, located in a catchment area surrounded by a number of

informal settlements, serves as an important facility for the poorest in the population. The relatively low price-

recovery percentages indicate that it is playing that role.

Table 5-6 : RUNH revenues from maternity clients

No. of clients

Revenue per client visit1 in Ksh.

Av. Payment as a % of official price2

Maternity Services

Normal Delivery 1320 7606.7 72.4

Caesarian 455 24402.0 85.6

Manual Vacuum Aspiration (MVA) 87 16257.8 108.4

Myomectomy 9 24528.8 98.1

Laparotomy 20 25728.4 102.9

CASH (Walk-in)

73%

Insurance/Company12%

Referrals15%


June 2015 Cardno 29

No. of clients

Revenue per client visit1 in Ksh.

Av. Payment as a % of official price2

Total Abdominal Hysterectomy 9 24580.1 70.2

Macdonald Stitching 11 8542.6 94.9

All Maternity Patient Services (weighted average) 77.8

MCH

Antenatal Care 2391 2103.9 87.4

Note:

1. This is computed as the total revenue divided by the total number of clients of the maternity and MCH services

2. This is computed as total revenue per client divided by what the hospital is currently charging per unit of

service

The findings above on the analysis of revenue-price relationship provide an indication of the degree to which

RUNH is responding to the diverse economic conditions that characterize the population that they serve.

However, the analysis cannot permit assessment of the degree to which revenues are sufficient to support the

institution's resource requirements. Such analysis would require linking revenues to the costs of production.

The analysis of revenue-cost relationships can be assessed on two levels, each of which provides a different

perspective on the institution's economic performance. First, for the institution as a whole, economic viability

requires that total revenues be sufficient to cover total costs, regardless of the degree to which the costs of

providing an individual service are covered by the revenues generated from payments for that particular

service. Secondly, understanding the cost-recovery experience for individual services provides a basis for

assessing the potential economic implications of changes in output mix and pricing policies. Both of these

aspects of cost-recovery would enable the hospital to identify the financial sustainability of providing maternal

and MCH services.

Referrals System

Ruaraka Uhai Neema Hospital was established as a referral medical center to guarantee access to health for

the poor population of the most marginalized areas of Nairobi, as well as a primary health provider for basic

and preventative medicine to the population of the informal settlements of Nairobi North East region. In

providing access to maternal and child healthcare in the Kasarani community and its environs, RUNH currently

partners with five health clinics located in the slums and has an established ambulance service for emergency

cases. The five clinics are: Baraka Health Center in Mathare area, Provide International located in Korogocho

and Dandora, Tumaini Clinic in Korogocho, NCCK Huruma Clinic in Huruma area and Redeemed Gospel

Church in Baba Dogo. Patients referred from these clinics are treated free of charge. Also, the hospital has

networks with CBOs, local and international NGOs, FBOs, youth groups and Government health facilities

mainly health centers. Out of 41 partners, 15 are clinics, majority being private clinics (14 out of 15).

Currently, RUNH has a formalized maternity and MCH referral system with its partners. The present system

includes a common understanding and acceptance of the referral pattern outlining who will be treated and

under what circumstances. Most of the partners refer for services not provided by the referring facility and in

cases where the provider/facility cannot serve the particular patient with that services (e.g. due to complications

requiring higher level care and or lack of supplies. The partnering or referring facilities are supposed to identify

clients with complications and refer them for specialized antenatal and delivery care at RUNH. Some of the

health facilities are working with Community Health Workers (CHW) and Community Health Volunteers (CHV)

to identify poor patients from the community. To verify the socioeconomic level of patients, some partners use

place of residence, occupation, and access to financial services as explained in the excerpt below.

So, we will look at the socioeconomic factor individual by individual. First, we have to check to see if

this person comes from Mathare. Then we will check whether this person has a profession, whether

she is a teacher, is the person working somewhere. That will be able to tell us if this person is

economically or financially stable and can be able to support herself. We ask for things like NHIF card,

whether they have a medical cover, and things like that. That will tell us more whether this patient is


June 2015 Cardno 30

eligible for the programme or not. Of course, most of them . . . 80 percent are poor, but we cannot

maintain them. [KII-Health Facility]

In the facilities, doctors, clinical officers and nurses refer patients. Upon arrival of the patient at the facility, a

medical provider makes observations to verify the patient’s condition and writes the medical history before

making referrals. Key Informants explained methods used to communicate referrals to RUNH facility. The

majority of providers across partner facilities reportedly use of a referral form. Others use referral tally sheets

and handwritten notes on exercise books devoted to referrals. In most cases, the referring facility fills the

referral form with clients’ detail information such as age and sex, referral date, reason for referral (diagnosis)

and patient’s socio-economic background which acts as a “filter” for assessing the patient’s ability to pay for

healthcare.

“Normally, after the tests, the clinician is the one that will decide whether the patient can be managed

from here or must be taken to the hospital”. [KII-Health Facility]

Barriers to the referral

Key informants were asked what challenges/constraints influenced the functioning of the current referral

system. In general, healthcare providers identified lack of transport, clients’ attitudes, lack of funds/poverty and

culture as some of the challenges facing the existing referral system.

Lack of transportation - Lack of transportation was cited by all contacted partners as the main barrier to the

referral system. Many of the partners lack infrastructure for ambulance services and rely on one currently

operated by RUHN. However, it is not able to meet the current demands. In the absence of ambulances, some

partners opt to use taxis, public transport, and motor cycle commonly referred as ‘Boda Boda’ to transport

clients for emergency care. Taxis are preferred to public vehicles due its convenience; however, they are

usually an expensive means of transportation.

Delays in making the referrals - The aim of any emergency transportation system is to ensure that a woman

arrives at the appropriate health care facility in the most timely and comfortable manner possible. A common

challenge affecting the referral system is related to clinic operating hours since most of the partner do not offer

24-hour services and are closed over the weekend. Sometimes, there are delays in referrals of patients who

need emergency services at night or during the weekends as explained in the following statement by one of

the services provider.

We do not work 24 hours and during weekends. So, you can imagine when labour starts and this

person has to go to Neema. Neema is not a place you can walk to. One has to take a taxi, a boda-

boda or any other means. So when it happens when we are not working, then it becomes a challenge

to the patient. That is why some of them end up delivering with traditional birth attendants. Neema has

an ambulance, but they do not allow patients to call it directly except through a healthcare facility. We

also have an ambulance, but because we do not work 24 hours, actually after 5pm, we do not work,

and then over the weekends. [KII-Health Facility]

Lacks of funds - Some of the local partners lack funds and capacity to facilitate their operations. The lack of

local level implementation is hindering smooth referrals and coordination as well as awareness of services

available. Some of the partners depended on donor funding in the past to implement and coordinate the

referrals, however, this stopped with the cessation of the donor support.

“So, you see, we now do not have a source of funds….that is why we stopped referring our patients.

For sure, it was expensive to the school. Many people wanted us to continue, but we could only support

a few because due to a lot of expenses. We realized we could not sustain the referral once those who

supported us with finances stopped.”[KII-FBOs]


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Client’s preference - While the decision to refer is mainly decided by the medical staff, some clients have their

preferred facilities. As a result, service providers may have no choice but to refer clients to their choice of

facilities.

Poor Health seeking behavior - A patient’s lack of knowledge of MCH may keep her from complying with

referral advice. Providers interviewed cited referral non-compliance due to patient misunderstanding as a

barrier. The majority of health providers viewed women’s lack of knowledge about their health and the potential

or actual health threat as common among those living in poor settings. Delay in seeking health care also

featured during the interviews with key informants as a challenge to the referral. Respondents observed that

some pregnant women prefer to consult traditional birth attendants (TBAs) rather than go to a health facility

for care. Such practices in a way can keep them from complying with medical advice and MCH referrals.

“…, ignorance is a problem. You will find that they fight the information. You will still find that the

antenatal mother does not prefer to visit a modern health facility but go to the traditional birth

attendants”. [KII –Health provider]

Loss of follow-up - Some of the partners are not able to track some of the patients they refer mainly due to the

weak counter referral system. Hence, it is very difficult to know whether referred clients complete the referral

process.

Delays at the referral clinic -The waiting time between the referral and patient first contact with the doctor/nurse

was mentioned as a challenge. Respondents lamented that sometimes it takes longer for the referred patient

to be served. The long waiting time was attributed to some factors including many clients, few doctors and

nurses. The wait is often frustrating to those accompanying the patient. Related to the delay is the aspect of

patient ‘getting lost'. Discussion with partners revealed that new referral patients were often ‘getting lost' upon

arrival at a health facility, and that some patients, despite being referred from the community, were still not

receiving all the services they needed. There is a need for a specific person assigned to help them navigate

the system.

Perception of MCH services quality and affordability

To further understand how referrals are functioning and to identify inefficiencies from the demand-side

perspective, a series of FGDs were held with pregnant and lactating women from three different sites (Mathare,

Korogocho and Zimmerman). The majority of mothers living in these areas rely mainly on the government

health facilities for maternal and child health care services; Public health centres were frequently mentioned.

Focus group discussions revealed that government health centres were preferred due to accessibility and

affordability. Accessibility was mainly described in terms of distance to the health facility and cost of healthcare.

The cost of health services from private hospitals was viewed as more expensive compared to public health

facilities.

“I prefer government because I do not have the money to go to private hospitals around here. I only

have fare to take me to the hospital and back. In government hospital, you will be treated even if you

do not have the money”. [FGD-Pregnant and Lactating women]

Although many of the FGD participants obtained maternity and child health services from government health

facilities, they expressed their perception of the health facilities that could have an impact on access to care

on MCH services utilization, including referrals. The choice of health facility was mainly determined by the

following factors; quality of care, access to services, cost of services availability equipment and qualified staff

and health provider attitude

The quality of care - FGD participants expressed the quality of care as having a significant influence on their

choice of a health facility. Elements of the quality of MCH services expressed by the participant includes; the

reputation of the health facility, cleanliness and tidiness of the facility, staff courtesy and friendliness, previous

experience (impression).

“To me, quality service means that when I go to a health facility, my baby and I are received well and

treated well. The health practitioners at the facility must communicate well with me. They must also


June 2015 Cardno 32

listen to me. In County Council facilities, they do not listen to patients. They will rush you through as

you try to explain your condition to them. They must also explain to me well what I am supposed to do

after leaving the hospital”. [FGD-Pregnant and Lactating women]

Accessibility - Accessibility was discussed as having a major influence on the choice of the health facility to

seek MCH services. Participants mainly described accessibility in terms of location of the health facility, waiting

time in the health facility and working hours of the health facility.

Cost - Cost was also viewed as a major factor in the utilization of public health centers rather than private

facilities. Public facilities compared to private facilities were preferred by many respondents on account of free

MCH services. However, many of the participants were not satisfied with the services from public health

centers. Respondents cited poor quality service due to long waiting time, lack of equipment and drugs as some

of the challenges experienced from public health centers.

Availability equipment and service providers - The decision to attend a healthcare facility is also influenced by

the availability of equipment and service providers at the health facility. Patients prefer to seek health services

from facilities with adequate facilities such as X-rays, laboratories, pharmacy, etc. Also, facilities with adequate

qualified staff and offering information to clients are preferred.

Opportunity for improving the referral system

Despite the challenges highlighted above, there exist opportunities to improve the existing referral system.

Awareness of RUNH

A census was taken during the FGD on the number of participant awareness of RUNH and the services offered.

The results revealed that the majority (six out of ten) were aware of the existence and location of RUNH and

came to learn about the health facility through word of mouth-mainly through friends and relatives.

Outreaches/medical camps

The community outreaches and medical camps is an opportunity to improve on the referrals. Through such

initiatives, RUNH can educate the community on MCH and the appropriate use of the local referral system.

Part of the strategy may include information provision on pregnancy danger signs and referrals. The community

outreach health sessions on free-of-charge health care services, as well as general MCH topics with an

emphasis on ANC, postpartum care, delivery and newborn/child health danger signs would be important

strategies to ensure that women know when to seek care and why.

Existing partnership

The current partnership between RUNH and other health actors presents an opportunity which can be

harnessed to improve the referrals. In the future, RUHN should consider public-private partnerships with the

government facilities and adopt innovative structuring of partnerships as a means of keeping costs low.

Poverty measurement

It is important to measure poverty in a community in order to reach the very poor and to ensure that they are

not discriminated. Poverty is multi-dimensional in nature and can be measured in a number of ways. Some of

the methods used to measure poverty such as asset indices and Income/Expenditure is costly and time

consuming. In addition, they are too general to illustrate effectively the reality of individual household and

community. Poverty measure such as living in less than one dollar per day may not effectively identify the

poorest.

Participatory approaches which allow a member of a community to express the reality of their poverty has

been used to address this shortfall in poverty measurement. Within the informal settlement settings,

households can be classified into very poor, poor, middle and rich using the following conventional indicators;

> Earning -wage earners, household income, profession, savings and loans.

> Dwelling unit -housing structure, size of accommodation, rental status/ownership status.

> Facility/Services -cooking facility, furniture, household asset, access to water, toilets facility and

access to electricity.


June 2015 Cardno 33

> Nutrition - number of meals per day, frequency of nutritious meals.

> Others - clothing, education, child labor, access to health services.

Using scoring system to grade household poverty

Extreme poverty in informal settlements is varied and there is no one criterion to measure it. If a household

were to have the lowest level of each of the above-cited indicators, it would be very poor; if it were to have the

second level of each indicator, it would be poor. Considering that households rarely have the same level of

indicators, there is a need of scoring to grade the households. A proposed poverty screening tool is presented

in Appendix 3.


June 2015 Cardno 34

6 Discussion

The disparities in access to health care across socioeconomic groups are the key reason for the major

discrepancies in health status between wealthy persons and poor persons. In addition, other factors may work

to create major impediments/barriers to access healthcare. This study, while acknowledging the spectrum of

contributing factors, establishes whether the cross-subsidy model being implemented by RUHN is actually

increasing the number of poor patients accessing health care particularly, maternal and child health services.

This was achieved by examining the trends in the number of clients by various socio-economic variables

(education, occupation and place of residence). The findings shows that the majority of Maternity and MCH

clients have post-secondary education (40%) with little variation in the average number of patients each year.

The majority of clients are engaged in some kind of economic activities with the main occupation being self-

employment/small scale businesses (34%) followed by working in sale/service/clerical jobs. According to

(Andrulis 1998), complexity of socioeconomic characteristic, especially in understanding the use of healthcare

exist. It is generally understood to encompass not only income and education level, the measures most

commonly used, but also a wide range of associated factors that may affect the quality of health care patients

receive, including insurance status, access to care, patients’ health beliefs and many facets of the doctor-

patient relationship, such as trust and communication.

The literature provides a wealth of information on the barriers to accessing health services faced by the poor

living in urban and rural communities. These barriers can be categorized as obstacles of availability (physical

accessibility), affordability, appropriateness and cultural acceptability. Physical accessibility can be addressed

by providing culturally secure transport to get clients to where a service is provided. Additionally, services

provided closer to home (that is, closer to residential areas inhabited by large numbers of poor families), in

non-standard settings and providing some services through home visitation may improve physical access. In

addition, cross-subsidization has been identified as a way of improving access to healthcare by the poor as

indicated above.

The existence of potential cross-subsidies is an essential component of a successful cost-recovery strategy.

In general, the institutional setting within which revenues are shared needs to produce a mix of services which,

on average, generate sufficient revenues to cover their costs. For any individual service, however, this

condition may not be achievable. The analysis above provide some evidence that RUNH, serves as an

important facility for the poorest in the population as evidence in the relatively low price-recovery percentages

of maternity and MCH services. However, there is a need to conduct a comprehensive cost recovery analysis

for maternity and MCH services to establish exact financial sustainability.

Currently, RUNH has a well-structured referral system with its partners. The referral system outlines who will

be treated and under what circumstances. Most of the partners refer for services not provided by the facility

and in cases where the provider/facility cannot serve the particular patient with that service (e.g. due to

complications requiring higher level care and or lack of supplies), the referring partners screens needy patients

based on place of residences, profession, and access to financial services. However, there are challenges

affecting the functionality of current referral system. A common barrier to referral noted by all provider groups

was the cost of care while facility-based providers also placed importance on transport as well as delays at the

referral clinic. Other challenges include; lack of funds to facilitate referrals, delays in making referrals, poor

health seeking behaviour and loss of follow-up-to referred clients. Partners and facility-based providers alike

described a need for priority to be given to clients that are referred upon arrival at the referral site. Partners

also feel that increased communication between community and facility and between facilities will improve

client care by providing necessary information to the referral site and feedback to the referring site to support

the continuum of care.


June 2015 Cardno 35

7 Recommendations

Referrals

> Strengthening local coordination structures.

> Expand partnerships particularly with Government health facilities.

> Establish linkages with community structures such as CHW and CHVs.

> Expand on current outreach programmes to include other informal areas currently not covered.

> Address late/delayed treatment of referred clients at the referral facility.

> Conduct consultative meetings with partners providing health services to standardize referral

procedures including transportation of needy patients.

> Establish a monitoring and evaluation system for referrals to inform the improvement of counter-

referral procedures.

> Improve on data collection especially at the registration point to ensure all socio-economic data of

patients seeking health services at RUNH are captured.

> Improving institutional and community linkages by integrating community resource persons into the

health and referral system to mobilize communities and create more demand for services.

> Raise awareness of complications and danger signs of maternal and child health at the community

level.

> Explore locally available resources for emergency transport and communication.

Sustainability

> Conduct a comprehensive cost-recovery analysis for all hospital departments to establish financial

sustainability.

> Improve on capturing socio-economic data of patients seeking health services at the registration

point.

> Pilot the Poverty Screening Tool developed by referral partners to authenticate the socio-economic

status of clients before referral.


June 2015 Cardno 36

8 References

Andrulis, D.P. 1998. "Access to care is the centerpiece in the elimination of socioeconomic disparities in

health." Ann Intern Med 129(5):412-416.

Aravind Eye Care System. 2011. Social Enterprise Institute Case Series Publications. Avaliable at

http://hdl.handle.net/2047/d20004776.

Bhattacharyya, O., S. Khor, A. McGahan, D. Dunne, A. Daar, and P. Singer. "Innovative health service

delivery models in low and middle income countries - what can we learn from the private sector?"

Health Research Policy and Systems C7 - 24 8(1):1-11.

Fjell, K. 2001. "A cross-subsidy classification framework." Journal of Public Policy 21(03):265-282.

Gruber, Jonathan. “Religious Market Structure, Religious Participation and Outcomes: Is Religion Good for

You?” Advances in Economic Analysis and Policy 5, 1 (2005).

Guy, D., R. Lindrooth, L.A. Helmchen, and L.R. Burns. 2011. "Do Hospitals Cross Subsidize." NBER

Working Paper No. 17300.

Heras-Muney, A. 2005. "The Relationship between Education and Adult Mortality in the U.S." Review of

Economic Studies 72:189-221.

International Institute for Population Sciences (IIPS) and Macro International, 2007. National Family Health

Survey (NFHS-3), 2005-06, India: Key Findings. Mumbai, India

Kenya National Bureau of Statistics (KNBS) and and ICF Macro. 2010. "Kenya Demographic and Health

Survey 2008-09." Calverton, Maryland: KNBS and ICF Macro.

Ziqitza Health Care Limited. 2012. "About Us Avaliable at http://zhl.org.in/aboutus.html."

http://hdl.handle.net/2047/d20004776

http://zhl.org.in/aboutus.html.


June 2015 Cardno 37

9 Appendix 1: Partner Key Informant Interview Guide

PARTNER IDENTIFICATION

NAME OF INSTITUTION OR FACILITY:_____________________________________________

LOCATION (community and city and district):_______________________________________

Type of Facility:

NGO/CBO 01

Private for-profit 02

Faith-based organization 03

Other (Specify): _______________________ 04

BACKGROUND DETAILS OF KEY INFORMANTS

Respondent Name: ______________________________________

Position/Responsibility: __________________________________

Contact Information:

Telephone: ___________________________________ E-mail: _______________________________

DATE OF INTERVIEW (dd-mm-yy): - -2015

TIME STARTED (24 hours) (hh-mm): :

TIME ENDED: :

Name of Interviewer______________________________________

Understanding of services offered by the Partner 1. What type of health services does your organization or facility provide to the community?

2. What are the most frequent services you are able to provide (e.g top three to five)

3. Are the services you provide facility-based or community-based or both?

4. What is the average number of clients you see per month?

Target population 5. Who are your clients? (age, gender, education level, occupation, in formal employment)

6. Describe your clientele (socio-economic profile)


June 2015 Cardno 38

7. How do they pay for services rendered (mode of payment – cash, kind, insured etc)

8. Generally, in your opinion, do you think the cost of services prevents a large number of clients from

accessing services? Please explain your answer. PROBE for specific services cost

Referral Patterns and Processes 9. Please list the names of the organizations or facilities you most commonly refer your patients to.

10. Does your organization or facility use a referral system to link patients to other services? (Please

describe the referral system in place) (Probe for the method(s) and the processes that are used to refer

clients)

11. Please describe who identifies and assesses client needs and makes a referral.(Probe for factors

considered)

12. Is there a formal agreement between your organization or facility and receiving institutions? If so, please

describe the type of agreement in terms of :a) what is covered? b) Whether all service providers are

included?

13. What are the services for which your organization refers clients elsewhere?

14. Describe the most common conditions that your organization or facility refer out and why?

15. Please describe how you know about the services that are offered by other providers to which your

organization makes referrals.

16. Does your organization have a record keeping system to keep track of outgoing clients?

17. Is there a system in place to measure and record a time lapse between when a referral was made and

when a client reached the receiving provider?

18. Are clients ever referred back to this organization or facility for follow-up after referral services are

received? IF SO, explain the process.

19. Is there a system to inform your facility or organization that a client has completed the referral?

Challenges to the referral system 20. What are some of the challenges or constraints you currently face that influence the functioning of the

existing referral system?

Recommendations 21. Do you have any recommendations on how the monitoring of referrals could be improved?

22. Do you have any recommendations on how the referral system could be improved?


June 2015 Cardno 39

10 Appendix 2: Focus Group Discussion Guide

NAME OF THE INTERVIEWER

NAME OF THE NOTE TA KER

AREA

DATE OF INTERVIEW (DD-MM-YY

TIME STARTED (24 HOURS) (HH-MM)

TIME ENDED: (24 HOURS) (HH-MM

BACKGROUND CHARACTERISTICS OF THE FGD PARTICIPANTS

No Name Age Level of education Occupation Signature

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Description of the Community

1. Tell us a little bit about the community you live in (Probes: Environment? What kinds of things do

people do to make their living? What kinds of houses do people live in? Where do children go to

school?

Accessibility of MCH services

2. What are the different places in your community that pregnant and lactating mothers (including

yourself) go for Maternal and child health care services such as ANC, Delivery, and Immunization

e.t.c? (Probe for

3. How would you describe these facilities? (i.e. government, private, or NGO; affordable vs. expensive;

trustworthy vs. not trustworthy, distance etc (Probe for each facility mentioned)-

4. What are the main reasons for your choice of [Name of facility] for MCH services?

Awareness of RUNH

5. Take a census of those who have heard about RUNH [Probe for how they came to know about it]-

6. If aware of RUNH, what kind of health services is currently provided at RUNH?


June 2015 Cardno 40

Quality of MCH services

7. From your own perspective, please tell us what you understand about quality of care that is provided

to pregnant women and lactating mothers as well as their children?

8. Where can people in your community get high quality MCH health care services? [Probes: How do

you know this? Through personal experience? Word-of-mouth? etc]

9. Are you aware of any of the facilities that offer high-quality and affordable MCH health care services?

Probe: which ones?

Challenges and Recommendations

10. What challenges do you face in accessing MCH health services? (Probe for distance, lack of facilities,

hostilities, discrimination, provider attitude etc)

11. What do you think should be done to improve access to MCH health services?


June 2015 Cardno 41

11 Appendix 3: Poverty Screening Tool

Fist Name________________________ Surname__________________________

Sex______________ Age_________ Marital Status_____ Number of children___

Indicator Score Means of verification

A: Living Space

Shares one room with other family 1 Observation and Question

One small room for whole family 2

Two small rooms or one large room 3

Two or more rooms with additional space 4

B:House structure

Floor/wall/roof-Natural (Earthen, cow dung, grass thatched, makuti etc

1 Observation and Question

Floor/wall/roof (Made of rudimentary materials-, polythene bags, wood planks, cardboard etc)

2

Floor/wall/roof-Cement, bricks, iron sheet 3

Floor/wall/roof-tiles, vinyl , carpet, Parquest or polished wood 4

C: Rental status

Monthly rent Ksh. 2500 or less 1

Monthly rent Ksh. 2500-5000 2 Question

Monthly rent Ksh. 5001-10000 3

Monthly rent above Ksh. 10000/Own the structure 4

D: Cooking facilities

No separate cooking space-waste materials used for fuel 1

No separate cooking space-wood, kerosene used for fuel or electric heater

2 Observation and Question

Separate cooking space- stove, earthen oven, electric heater or gas oven used

3

Separate cooking space- gas oven used, rents out gas oven 4

E: Average number of meals per day

One meal 1 Question

Two inadequate meals 2

Two adequate or three inadequate meals 3

Three adequate meals 4

F: Type of work

Unemployed 1

Casual Laborer 2 Question

Business/self-employed 3

Professional 4

G: Monthly Income (Ksh.)

<5000 1

5001-10000 2 Question

10001-20000 3

200001 and above 4

TOTAL SCORES [A+B+C+D+E+F+G]

Scale

Poverty bands Score

Very poor 7–11

Poor 12–16

Middle 17–21

Rich 22–28


June 2015 Cardno 42

ruaraka uhai neema hospital

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