Health Service Provision in Kenya:
Assessing Facility Capacity, Costs of
Care, and Patient Perspectives
Dr Caroline Kisia
Action Africa Help - International
26th Nov. 2014
Presentation Outline
• Background to the Study
• Study Objectives
• Methodology
• Results
• Conclusions
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Background to the Study
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Background
• Kenya’s new Constitution – citizens’ right to health
• Devolution of healthcare service provision to Counties
• Limited health care budgets
• Need for evidence to guide policymaking and resource allocation
• Multidimensionality of health system functions
• Comprehensive and detailed assessment of the healthcare system
performance rarely occurs
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Overview of the ABCE Study
• A collaborative project between Action Africa HelpInternational (AAH-I) and the Institute for Health Metrics and
Evaluation (IHME), an independent global health research
center at the University of Washington, Seattle
• Launched in 2011
• Funded through the Disease Control Priorities Network
(DCPN), a multiyear grant from the Bill & Melinda Gates
Foundation
• To comprehensively estimate the costs and cost-effectiveness
of a range of health interventions and delivery platforms
• A Multi-country Study allowing for comparisons
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Objectives of the Study
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Objectives of the ABCE Study
• The ABCE project aimed to
answer the questions of :
– What is the Cost of producing
health services?
– Who is Accessing these health
services?
– What Bottlenecks exist to health
service delivery expansion
– How Equitable is access to health
care services?
– What Tools exist for real-time
monitoring and tracking health sector
growth?
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Methodology
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Study Design
Sample design
• Stratified random sampling - nationally representative sample of health facilities
Step 1: Counties from which facilities were drawn were initially grouped into 27 and later into
16 unique categories based on their:
• Average malnutrition rates – low, middle and high
• Health expenditures – poor, middle and wealthy
• Population density - rural, semi-dense and dense
Nairobi and Mombasa were automatically included due to their size and relevance to Kenya’s
health service provision
18 counties were selected through the county sampling frame
Step 2: Entailed sampling facilities from each selected county across the range of platforms
i.e. channels identified as offering health services in Kenya.
254 facilities (excluding DHMTs) were randomly selected through the facility sampling
frame
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Sampling strategy for facilities
Data Collection
• Primary data collection took place from April to
November 2012
• Four main data collection mechanisms:
1. Existing data
2. ABCE Facility Survey – over 2,600 data elements
•
District Health Management Teams (DHMTs) received a modified
version of the ABCE Facility Survey.
3. Clinical chart extractions of HIV-positive patients on ART
4. Patient Exit Interview Survey
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ABCE Facility Survey
• Primary data collection from a
nationally representative sample
of 254 facilities
• Collected data on a full range of
indicators
o Inputs, finances, outputs, supplyside constraints and bottlenecks,
indicators for HIV care
• Randomly sampled a full range
of facility types
o National and provincial hospitals,
district and sub-district hospitals,
maternity homes, health centers,
clinics, dispensaries, VCT centers,
drug stores or pharmacies, and
DHMTs
Clinical chart extraction
• Extracted data on HIV-positive patients currently enrolled in ART
• Chart data included patient demographic information, ART initiation
characteristics (e.g., CD4 cell count, WHO stage, drug regimen, referral
points), and patient outcomes
Patient Exit Interview Survey
• Over 4,200 structured
interviews were conducted with
patients after they exited study
facilities.
• Questions included
•
•
•
•
reasons for the facility visit,
satisfaction with services
expenses paid associated with
the facility visit,
For the ART sub-sample HIVspecific indicators.
Results
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Facility capacity and service provision
Facility capacity and service provision
• Most facilities provided key health services
• Service was of varied quality
• Gaps were identified between reported and functional
capacity to provide care depicting an urban-rural divide.
• Availability of recommended equipment and pharmaceuticals
was moderately high, but varied within facility types.
• Facilities showed higher capacities for treating infectious
diseases than non-communicable diseases.
• Non-medical staff and nurses composed a majority of
personnel
• More urban facilities achieved staffing targets than rural
ones.
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Facility capacity and service provision
Gaps in reported and functional capacity for care
• Many facilities reported providing a given service, but then lacked
the full capacity to provide that service (e.g., lacking functional
equipment or stocking out of medications).
Facilities reporting
capacity
Facilities with functional
capacity
Antenatal care
89%
12%
General surgery services
58%
13%
Service
Facility capacity and service provision
Capacity for disease-specific case management
Facility capacity and service provision
Human resources for health: personnel composition
Facility production of health services
Facility production of health services
• ART patient volumes quickly increased at primary care
facilities; other patient visits were more variable over
time.
• Medical staff in most facilities experienced low patient
volumes each day.
• Facilities showed capacity for larger patient volumes
given observed resources.
• ART patient volumes could moderately increase given
facility resources, especially for district and sub-district
hospitals.
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Facility capacity and service provision
Outputs: average outpatient visits, by platform, 2007-2011
Facility capacity and service provision
Outputs: average inpatient visits, by platform, 2007-2011
Facility capacity and service provision
Outputs: average ART visits, by platform, 2007-2011
Efficiency and Cost of Care
Efficiency and Cost of Care
• Efficiency scores across platforms showed wide heterogeneity,
particularly within the private sector ranging from below 20% to
100%.
• On average, efficiency of public health facilities increased
along the levels of care, posting dispensaries at 46% and
national and provincial hospitals at 75%.
• In terms of spending, personnel accounted for the vast
majority of annual expenditures across facility types.
• On average, facility costs per patient varied markedly across
facility types
– cost per outpatient visit ranged from KShs 342 at public dispensaries to
KShs 2,825 at national and provincial hospitals.
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Efficiency and costs of care
Efficiency scores across platforms, 2007-2011
Efficiency and costs of care
Estimated potential for expanded service production, 2011
Patient perspectives
Patient Perspectives
• Most non-HIV patients had medical expenses, whereas few
ART patients reported paying for care
• Most patients spent less than an hour traveling to facilities,
whereas waiting times for care varied more
• Patients gave high ratings for facility providers and slightly
lower ratings for facility-based qualities
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Non-HIV patient perspectives
Patient reports of expenses associated with facility visit, 2012
17314
13942
12274
12253
13630
12722
14347
13804
12393
16437
14812
17743
15465
11239
17555
16060
15878
11676
11873
11785
0
.2 .4 .6 .8
1
Pub. Disp.
17517
16267
14479
13481
13094
12789
12371
10728
11657
10907
14665
17352
13821
13049
12489
13017
10862
15640
10938
11797
17492
12979
13550
13625
12077
13680
14897
15068
13656
12255
12626
12094
13663
11861
12719
15739
14321
13805
11740
10171
15074
12618
15311
10890
14555
16157
11522
15288
13939
15204
10903
13194
12004
13023
12438
11510
15915
0
.2 .4 .6 .8
1
Dist. Hosp.
13865
17862
Pub. HC
10979
15722
13088
12512
14822
17595
12995
16450
15605
12179
10774
14025
12521
11936
13969
16463
12130
10655
15312
14131
11170
10878
14453
10671
13239
13779
13778
10829
11436
11004
15197
1
Priv. Hosp./Maternity
13892
.2 .4 .6 .8
N/P Hosp.
13897
13517
15209
16098
13006
15753
15616
11995
15866
11499
11472
15649
14101
14098
14014
13629
12643
12013
10058
10438
10940
16742
14139
11955
14061
13011
11573
13098
12413
15104
13595
13014
11434
11235
15946
11774
10294
10974
15880
0
Percent of patients ‘very likely’ to return to this facility
if needing health services in the future
SD Hosp.
Priv. HC/Disp.
Conclusions
Conclusions
• This multidimensional assessment provides a unique
perspective on health facility capacity, costs and quality of
care.
• The study indicates that there is room to utilize existing
capacity to expand healthcare service provision at a relatively
low marginal cost.
• Further analyses on this front would provide helpful insights
towards Kenya’s aspirations of universal health coverage.
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Acknowledgements
Acknowledgements
• This study was made possible through the efforts of a
number of institutions and individuals:
– The Institute of Health Metrics and Evaluation/UoW – managing the
ABCE project grant and providing the technical team for the study
– Bill & Melinda Gates Foundation for providing funding
– The Ministry of Health, Kenya for supporting the study
– The 24 Research Assistants who conducted the field work
• The co-authors of the abstract from:
• AAH-I (Ms Ann Thuo),
• AAH Kenya (Ms Caroline Jepchumba & Dr Githaiga Kamau)
• IHME-Africa (Prof. Tom Achoki)
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For further
information,
below are our
contacts
FAWE House, Chania Avenue
P.O. Box 76598 00508
Nairobi, Kenya
Mobile: +254 (0) 20 3007755/6
www.actionafricahelp.org
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