Health infrastructure is critically important in achieving Universal Health Coverage (UHC). According to the Ministry of Health, health infrastructure is defined as ‘all the physical infrastructure, inpatient beds, equipment, transport and technology (including ICT) required for effective delivery of services at the National Government and County Government level.’
The World Health Organisation (WHO) on the other hand defines UHC as a health system where all people can access necessary health services; for example, prevention, promotion and treatment, rehabilitative and palliative care without the risk of financial problems. The right to use of health facilities, therefore, goes hand-in-hand with not only adequate availability of health infrastructure but also the requisite provision of high quality health service.
The state of health infrastructure in Kenya is not that rosy, considering the significantly low bed density of 14 beds per 10,000 population, compared with the global average of 27 beds per 10,000 population. Physical health infrastructure, especially buildings, are in a dilapidated state, have inadequate space and are not prioritised by both National and County governments as areas of critical investment. The situations is made worse by political interference where local politicians want to dictate where health facilitates should be constructed or determine their distribution.
However, it is worth noting that a number of counties have also procured state-of-the art ambulances, with Machakos leading with 70 followed by Meru with 24. Some counties have also modernised some of their health facilities to facilitate provision of quality service delivery and referral services. On the other hand, a policy brief by the Ministry of Health titled ‘Pathways to Optimal Health Infrastructure in Kenya’ highlights not only the infrastructural gap, but also inadequate technical personnel to operate fixed equipment and machines, where they are available. An analysis of statistical information in the Kenya Economic Survey 2019 on health infrastructure is discussed based on trends in medical clinics, dispensaries, health centres, health facilities and hospitals as follows.
Medical clinics
Statistical information from the Kenya National Bureau of Statistics (KNBS) Economic Survey 2019 indicates that between 2014 and 2018, the overall number of medical clinics (Level 2) owned by public, private, faith-based organisations (FBOs) and non-governmental organisations (NGOs) grew from 2,575 to 3,646, respectively. Majority of them were privately-owned medical clinics, whose number increased from 2,427 to 3,437 between 2014 and 2018, respectively. In 2014, private medical clinics accounted for 94.25 percent of the overall medical clinics compared with 94.26 percent in 2018. NGO-owned clinics increased from 146 to 194 in the same period. Publicly-owned medical clinics grew from two in 2014 to eight in 2018. There were no FBO medical clinics between 2014 and 2017. However, provisional statistics for 2018 put the figure of FBO medical clinics at seven. Figure 1 below provides a more detailed illustration of trends in medical clinics from 2014 to 2018.
The low number of publicly-owned medical clinics is a matter of grave concern, especially with regard to the low level of access to affordable and high quality UHC at the grassroots level. The significantly predominant number of privately-owned medical clinics means that many poor and indigent people who are not covered by any health insurance, suffer financial hardship in trying to access health services and/or are forced to use alternative and often unsafe traditional healers.
Dispensaries (Level Two)
Unlike in medical facilities where private facilities were in the majority, the number of dispensaries were mostly publicly owned, having increased from 3,225 in 2014 to 3,646 in 2018. Publicly owned dispensaries accounted for 84.1 percent of the total. Dispensaries owned by faith-based organisations increased from 656 in 2014 to 683 in 2018, respectively (Figure 2). There were no privately and NGO-owned dispensaries for the period 2014 to 2017. However, it was projected that there would be three of each in 2018. The high number of publicly owned dispensaries is a boon to UHC as they can help implement it. However, majority of dispensaries and health centres do not provide comprehensive basic healthcare as many of them were elevated to Level 4 facilities without the resources to offer basic healthcare.
Health centres increased by 3.1 percent to 1,806 in 2018 and most of them were publicly-owned. On the other hand, Level 4 and 5 hospitals grew from 668 in 2014 to 771 in 2018. Despite this scenario, there is still a critical need to upgrade, expand health infrastructure and adequately equip them to support UHC.
Transport
In terms of transport infrastructure, most of the counties have purchased ambulances but others have a huge deficit. Ambulances are supposed to reach the scene within 15-20 minutes after an emergency call and move the patient to a health facility within the next 20 minutes − a rare occurrence in Kenya. The World Health Organisation (WHO) requires at least one ambulance to serve 70,000 people. The transport infrastructure should also consider the state of roads, which in some counties are still almost impassable, especially during the rainy season. This can frustrate accessibility to quality health care and may lead to financial hardships, especially in counties with a shortage of ambulances. In this scenario, patients have no choice but to use private transport, which is unaffordable to many. This is coupled with a lack of emergency call centres for coordination of transport, and proper management of intra and extra county emergency services − to benefit from pooled inter-county resources.
The Ministry of Health Policy Brief 2018 on Infrastructure also acknowledges the limited access to communication equipment and technologies among health service providers throughout the country. National and County governments, therefore, need to invest in communication technologies that ease access and use of health services in Kenya.
Ministry of Health findings (2017/2018)
These findings are based on the Kenya Harmonized Health Facilities Assessment (KHHFA) 2018, which was carried out by the Ministry of Health (MOH), working together with development partners such as the WHO, Japan International Cooperation Agency (JICA), United Nations Children’s Fund (Unicef), United Nations Populations Fund (UNFPA), among others, who provided funding and technical support. The assessment aimed to provide external validation of information on availability of health service and readiness; and offer baseline information to facilitate health investments in Kenya through the implementation of UHC.
According to the WHO, general service readiness refers to overall capacity of health facilities to provide general health service. On the other hand, readiness is defined as the availability of components required such as basic amenities, basic equipment, standard precautions, laboratory test and medicines and commodities.
The modules assessed in KHHFA included:
Availability: collected information relating to physical presence of facilities, resources, and services;
Readiness: covered capacity of a health facility to provide specific services, such as presence of drugs, supplies, diagnostics and equipment;
Management and finance: collected data on practices to support continuous services availability and quality (e.g. management practices and supervisory practices);
Quality and safety of healthcare: Indicators of receipt of appropriate, effective and timely care by patients under safe conditions; and,
Community unit: Methods utilised to collect relevant data were key informant interviews with community health workers in all 47 counties and focus group discussions. The survey randomly sampled 2,980 health facilities out a total 10,535 from the Kenya Health Master Facility List that was used as the sampling frame for the survey.
Health facilities
Based on KMHFL, the national health facilities density in Kenya was 2.2 per 10,000 population, slightly surpassing the WHO target of 2 per 10,000. However, the report notes that 14 counties (accounting for 30 percent of the total number of counties) had health facilities density below the WHO target of 2 per 10,000 population.
Health workers
The national health workforce density is estimated at 15.6/10,000 compared with the WHO target of 23 per 10,000, highlighting a clear gap of 7.4. The health workers density is the number of health workers per 10,000 population by cadre and is an indicator of health workforce density. The report reveals that only four counties out of 47 have achieved well above WHO targets, as follows: Tharaka Nithi (33.8), Nyeri (31.0), Uasin Gishu (28.2) and Nairobi (26.3). This means that majority of the counties are understaffed and struggle to provide quality health care.
Dispensaries are critically important at the grassroots level in supporting delivery of UHC. The average number of all categories of nurses in dispensaries was one, compared with the national norm for dispensaries of four, showing a 25 percent gap in the staffing level of nurses in dispensaries. On the other hand, the average number of registered nurses was 0.69, compared with a norm of one, indicating a gap of 31 for every 100 dispensaries. The average number of enrolled nurses was 0.16, compared with a norm of two, while the registered midwives averaged 0.13 against a norm of one per dispensary, showing a gap of 87 midwives per 100 dispensaries. Clearly, midwifery is understaffed and can gravely hamper the provision of free maternity services.
Medicines
According to the WHO, essential medicines are those that satisfy priority health care needs. On the other hand, tracer medicines are used to examine access in terms of availability of essential medicines. Tracer items of assessment of general service readiness are:
- Haemoglobin;
- Whole blood glucose by glucometer;
- HIV rapid test;
- Malaria rapid test or smear;
- Rapid syphilis test;
- TB microscopy (by AFT light microscopy);
- General microscopy (wet mounts);
- Urine pregnancy rapid test; and,
- Urine dipstick.
The KHHFA 2018 report revealed that tracer medicine for infectious diseases had the highest availability at 70 percent of the 2,927 health facilities, while medicines for mental health and neurological disorders scored the lowest in terms of availability at 21 percent. Medicine for non-communicable diseases was available in 42 percent of health facilities. Notably, Marsabit County had the highest availability of essential medicines with 59 percent against a mean availability of 25 percent. This portrays a state of ill-preparedness in terms of provision of essential medicines for infectious diseases at county government level – a dangerous situation should there be a disease outbreak.
Infectious disease medicines
Dewormers (mebendazole or albendazole) capsules and tablets were found to be the most available, with a mean of 85 percent, closely followed by co-trimoxazole capsules and tablets at 78 percent. Ciprofloxacin capsules and tablets were at 75 percent and amoxillin capsules and tablets were at 72 percent. Others were: Ceftriaxone injection at 66 percent, metronidazole capsules and tablets at 65 percent, and fluconazole (antifungal) capsules and tablets at 45 percent. The national mean for availability of seven infectious diseases medicines was 70 percent.
Non-communicable disease medicines
The average availability of 23 non-communicable disease was paracetamol at 77 percent, followed by epinephrine injectable at 76 percent, hydrocortisone injection at 75 percent, and meprazole tablet at 68 percent. Others were Ibuprofen tablet and Prednisolone (63 percent), Flurosemisemide capsules and tablets at 59 percent, with the least available being Isosorbide dinitrate tablets (2 percent) and Gliclazide (8 percent). Overall, the national mean availability was below average, at 42.1 percent.
Mental health and neurological medicines
Countrywide, phenobarbital tablets were the highest available of the 14 mental health and neurological tracer medicines, with an average of 58 percent, followed by diazepam injection at 47 percent, Diazepam tablet at 41 percent and Amitriptyline at 38 percent. The least was Lithium tablet (1 percent), lorazepam injection at 1 percent, levodopa+carbidopa at 5 percent, and Valproate sodium tablet at 8 percent. The mean availability for the medicines survey nationally was a mere 21 percent.
Palliative care medicines
According to the WHO, palliative care is “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual”.
Paracetamol was the highest available tracer item for palliative care, with 77 percent of the 2,927 facilities assessed having the drug, followed by ibuprofen at 63 percent, hyoscinebutylbromide injection at 58 percent, and loperamide at 48 percent. Other palliative care medicines were as follows: metoclopramide injection (43 percent); dexamethasone injection (39 percent); senna preparation (laxative) at 20 percent; morphine granule injectable (10 percent); haloperidol injection (4 percent). The least was Loarzepam tablet at only 2 percent. Nationally, the mean availability of palliative care medicine was only 36 percent for the 10 palliative care medicines assessed.
Essential medicines
The WHO defines essential medicines as those that satisfy the priority healthcare needs of the population. They are selected based on the prevalence and public health relevance, evidence of clinical efficacy and safety, and comparative costs and cost-effectiveness.
On average, the availability of essential medicines was 44 percent. However, none of the health facilities had essential medicines on the day of the KHHFA 2018 survey. In terms of the general service readiness index, Kenyan health facilities had an index of 59 percent, translating to nearly 6 in 10 facilities being well prepared to provide health services. The highest domain score was that of basic equipment, with a mean score of 77 percent, followed by standard precaution with a mean score of 65 percent, diagnostics at 56 percent, basic amenities at 55 percent, and the lowest for essential medicines (44 percent). The mean availability of 25 percent essential medicines by county show that only 10 out 47 counties scored above 50 percent, with the highest – Marsabit County – scoring 59 percent. The low availability of essential medicines is a cause for concern. The WHO framework for health systems observes that a well-functioning health system ensures equitable access to essential medical products, high quality vaccines, safety, and efficacy and cost effectiveness.
Essential medicines for mothers
Nationally, availability of essential medicines for mothers was quite low at only 40 percent, with sodium chloride injectable solution being the highest at 78 percent, followed by Gentamicin injectable at 71 percent, and Benzathine benzylpeninllin powder for injections at 60 percent. Availability of Oxytocin injectable was at 55 percent, azithromycin capsules, tablets or oral liquid was at 49 percent, Metronidazole injectable at 47 percent, and Betamethasone or Dexamethasone injectable at 45 percent. Others were Methyldopa tablet (40 percent); Magnesium sulphate injectable (31 percent), Misoprostol capsules and tablets at 15 percent, with the least being Ampicillin powder for injection at 11 percent.
Essential medicines for children
According to the KHHFA 2018 Assessment Survey Report, the average availability of essential medicines for children countrywide was 56 percent. Paracetamol syrup/suspension had the highest availability at 85 percent; ORS sachets was at 82 percent, Zinc sulphate tablets or syrup at 81 percent, Artemisinin combination therapy (ACT) at 73 percent and Gentamicin injectable at 71 percent. Others which were the least available included morphine granules/injection/capsule/tablet at 19 percent, Ampicillin powder (11 percent) and procaine penicillin at 27 percent.
Medicine pricing
The price data was analysed for eight commodities out of 32 assessed, such as an antibiotic, an antifungal cream, a tocolytic, an inhaler and an injectable antibiotic. Patient procurement prices ranged from 0.6 to 3.15 for Level 5 and 6 hospitals, meaning clients paid lower prices for some medicines than the procurement prices, while for other commodities such as Amoxicillin 500mg capsule, clients paid three times more. In Level 4 hospitals, the patient price to procurement price ratio was 0.22 to 4.00, meaning clients for Ibuprofen were paying four times the procurement price. In health centres and dispensaries, the median price was Ksh 0, and this was because the government abolished user fees in government Level 2 and 3 facilities.
Laboratory
The KHHFA 2018 Assessment Report presents findings on laboratories based on diagnostic capacity, advanced diagnostic services, and diagnostic equipment availability as follows:
Diagnostic capacity
The average availability of diagnostic tests was 56 percent countrywide. However, it was revealed that 84 percent of health facilities had HIV diagnostic capacity, while 74 percent had malaria diagnostic capacity, followed by syphilis rapid test at 62 percent and urine test for pregnancy at 60 percent. Others were blood glucose tests at 54 percent, urine dipstick glucose and urine dipstick protein tests, both at 43 percent. Only 17 percent of health facilities had all the diagnostic items. Clearly, these findings point to poor diagnostic capacity in most health facilities across the country.
Advanced diagnostic services and diagnostic equipment
Availability of urine dipstick tests was generally high in the counties, with 10 scoring 100 percent, while the performance of two counties was below 30 percent. Data from hospitals that offer advanced diagnostic services reveal that the mean availability of tracer items was 40 percent. Urine dipstick with microspy was the highest at 68 percent, followed by full blood count with differential at 65 percent and gram stain at 55 percent. Others included; liver function test (54 percent), renal function test (54 percent), and serum electrolytes (51 percent). The least available was HIV antibody testing (ELISA) at 3 percent, syphilis serology (6 percent), and CD4 count and percentage at 26 percent.
On the other hand, the mean availability of high-level diagnostic equipment countrywide was 41 percent. Ultrasound was the highest available diagnostic equipment at 62 percent, followed by X-ray equipment at 53 percent and electrocardiogram (ECG) at 34 percent. The least available equipment was CT scan, at just 13 percent.
Beds
The KHHFA Assessment Report notes that the national average inpatient bed density is 13.5, which is way below the WHO target of 27 beds per 1,000 people. According to WHO, bed density is defined as the total number of hospital beds per 1,000 population. Additionally, the national average inpatient bed occupancy rate is 46 percent, way below the set target of 80 percent. Bed occupancy rate is defined as the ratio between inpatient beds occupied and beds available out of those provided. On the other hand, the national maternity bed density is 13.8/1,000, which is above the WHO set target of 10/1000.
Specialist care
Palliative care
Palliative care service availability was poor in Kenya, with just 3 percent of health facilities providing the service at the time of the survey. Nationally, just 1 percent of health facilities offer home-based care.
In terms of service readiness, the mean availability of tracer items for palliative care was 59 percent of the 140 health facilities providing the service. Countrywide, a dismal 7 percent of facilities had all tracer items. Iron or iron folic acid was the highest tracer item at 95 percent, followed by Acetaminophen or Ibufen tablets, capsules and intravenous for rehydration, both scored 89 percent, with vitamin A at 73 percent. The least available tracer item was intravenous nutritional supplement which scored 17 percent, and Buprenorphine or naloxone at 22 percent.
Rehabilitative Medical Care
According to the WHO, rehabilitation is defined as ‘a set of measures that assist individuals who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with the environment’. Rehabilitation measures aim at: prevention of the loss of function; slowing the rate of loss of function; improvement or restoration of function; and compensation for the lost function and maintenance of current lost function. Rehabilitation includes activities such as rehabilitative medical care, physical, psychological, speech, and occupational therapy, and support services.
The KHHFA report focused on the availability of relevant equipment and service readiness. The service availability of rehabilitative care services in health facilities with all items nationally was dismally low at just 4 percent. Secondary hospitals emerged as main providers of the services at 90 percent, with dispensaries coming at the tail end with 1 percent. Countrywide, the mean availability of tracer items for rehabilitative care service readiness was 36 percent. The national outlook in terms of service availability and readiness for rehabilitative care does not paint a rosy picture. Performance of individual tracer items assessed was generally below average, with dedicated therapy treatment space at 67 percent, measuring tape/goniometer (52 percent) and walking frames/crutches /walking sticks (51 percent), barely scoring above average. The least available tracer items were automatic equipment and booths (9 percent), parallel bars (23 percent), and equipment for paediatric rehabilitation (mats/toys/walking frames/standing frames) at 26 percent.
Comprehensive surgery
Availability of comprehensive surgical services among the hospitals assessed was 68 percent, while only 50 percent of public primary hospitals offered these services. Other services that scored 68 percent in terms of availability in hospitals were congenital hernia repair, club foot repair and cleft palate services. Others were episiotomy (64 percent), dilatation and curettage (57 percent), hernia repair (elective) (56 percent), obstetric fistula repair (36 percent), and vasectomy (29 percent). The least available comprehensive surgical services were cataract surgery (24 percent).
The performance of service readiness was not better either. The mean availability of tracer items in the hospitals that offer comprehensive surgical services was 70 percent. Health facilities with all the tracer items were at just 7 percent. The mean availability of tracer items for government-managed health facilities was 67 percent, out of which only 6 percent had all tracer items − unveiling a huge gap.
General emergency care
The KHHFA analysis of the general service availability of emergency service was restricted to 140 hospitals providing the service. The findings reveal that 24-hour pharmacy service was available in 71 percent of hospitals, 67 percent had 24-hour laboratory services, while a mere 8 percent of hospitals provided 24-hour surgical services with a surgeon and anaesthetist. Other emergency services available in hospitals were: 24-hour radiological services at 44 percent, medical and nursing staff assigned to remain on duty was at 36 percent, and core non-rotating providers attached to Emergency Rooms (ERs) at 28 percent. Only 21 percent of hospitals used a formal triage system.
In terms of provision of special services, just 25 percent of hospitals had a special emergency unit, while only 20 percent of hospitals had a 24-hour emergency unit. Basically, this means that access to emergency services is still wanting.
In terms of service readiness, only 20 percent of health facilities had all items, while the mean availability was at 68 percent. Adrenalin and atropine were found to be the most available medicines and commodities at above 80 percent, compared to sodium bicarbonate which was at 62 percent availability in all facilities. Availability of equipment was rather low, with the adult oropharyngeal airway set being at only 50 percent of the facilities. The least available − paediatric intubation set – was at just 27 percent of the facilities.
Emergency care: Quality services
In terms of service availability, 55 percent of facilities had the capability to measure vital signs in Emergency Room (ER) units, carry out emergency vaginal delivery (53 percent) and administer uterotonic drugs (49 percent). Only 43 of the facilities could perform neonatal resuscitation.
The service readiness score was high, with the mean availability of tracer items for emergency quality support services at 93 percent, while 85 percent of facilities had all tracer items.
On the other hand, availability of equipment for emergency quality support services was better, with both stethoscope and blood pressure apparatus standing at 94 percent, and thermometers at 91 percent.
Emergency care: Airway interventions
Findings on service availability in hospitals that offered emergency airway interventions through suction was 77 percent. Sixty eight percent of facilities used manual maneuverers (e.g. jaw thrust and chin lift). Other airway interventions were the use of oral-or naso-pharyngeal airway devices in 52 percent of hospitals, while placement of supraglottic devices was in just 40 percent of the facilities. The least available intervention service was endotracheal intubation at 39 percent and creation of surgical airways at 28 percent.
On the other hand, service readiness was poor as only 17 percent of facilities had all the items needed for airway interventions, with a mean availability of 50 percent. Availability of suction apparatus with a suction catheter was highest at 68 percent, while the least available were circothynoidotomy or tracheostomy sets at 24 percent. Availability of medicines and commodities was above average, with oropharyngeal airway for adults at 61 percent and oropharyngeal airway (paediatric) scoring 54 percent.
Emergency care: Breathing
Administration of oxygen was the highest intervention measure in emergency breathing interventions at 78 percent. This was closely followed by critical therapies for reactive airway disease, scoring 76 percent, and bag-valve-mask ventilation at 70 percent. Other emergency intervention measures were measurement of pulse oximetry at triage and measurement of pulse oximetry in emergency units, both scoring 58 percent. Some 37 percent of hospitals used placement of chest tubes. The least breathing intervention services were: non-invasive mechanical ventilation at 20 percent, invasive mechanical ventilation at 23 percent and use of needle decompression of tension pneumothorax, 33 percent.
In terms of readiness, the mean availability was below average, standing at 45 percent of facilities surveyed, while the facilities that had all items were a mere six percent. On the other hand, the availability of medicines and commodities, for example; micronebulizer, beclomethasone and salbutamol inhaler was just 33 percent in all facilities. Furthermore, availability of equipment for emergency breathing interventions among hospitals that provide this service was not good. The findings show that availability of resuscitation bag masks (adult) in hospitals was at 62 percent, pulse oximeters at 56 percent, chest tubes with insertion sets at just 44 percent and paediatric intubation (endotracheal tubes) at 36 percent.
Emergency care: Cardiac interventions
The most available medicines administered as a cardiac intervention measure were adrenaline at 88 percent of 411 facilities assessed, aspirin (for ischemia) at 67 percent and thrombolytics scoring just 32 percent. Other intervention measures reported were: Electrocardiograms (ECGs) at 32 percent, external defibrillation and/or cardioversion (20 percent), external cardiac pacing (16 percent) and pericardiocentesis (12 percent).
Facilities that had tracer items for emergency cardiac intervention services were assessed and the findings revealed that the mean availability of tracer items was well below average at just 40 percent. Facilities that had all tracer items were a meagre 1 percent, while availability of adrenaline was the highest at 96 percent, followed by external cardiac pacers at 90 percent.
Emergency care: Control of bleeding interventions
The KHHFA found that availability of services to control bleeding were relatively low, with only 58 percent of facilities sampled having the ability to perform packing and/or suture to control bleeding. Some 55 percent of facilities used external control of haemorrhage, while 32 percent of the facilities had the ability to apply arterial tourniquets. Just 9 percent could perform and interpret point of care ultrasound. The least available services were safe transfusion (including protocol for appropriate ratios for massive transfusion) at only 7 percent, while a mere 6 percent could apply pelvic binding or sheering.
Out of the facilities that offered emergency services, only 12 percent reported having the ability to apply a tourniquet as a bleeding control intervention measure.
Emergency care: Volume resuscitation intervention
The assessment report highlights that of the facilities that offer emergency interventions, the administration of oral rehydration was 65 percent, closely followed by establishing central venous access at 64 percent, and adjusting fluid resuscitation for malnutrition or severe anaemia at 53 percent. Others were: placing a urinary catheter (46 percent), administration for intravenous (IV) fluids (34 percent), placement of peripheral IV access at 9 percent, and performing venous cut-down at 6 percent. The least available was establishing intraosseous access at 5 percent.
Service readiness was good, with oral salt topping in availability at 85 percent, while the lowest was the device for intravenous injection at 3 percent.
For service readiness by facility type, secondary and tertiary facilities scored a mean availability of 70 percent. On the other hand, dispensaries scored a mean availability of just 40 percent, while medical clinics had only 41 percent. The mean availability of items was 44 percent, with just 1 percent of facilities having all the items for emergency volume resuscitation services among the facilities that provide this service.
Emergency care: Unconscious patient interventions
Service availability in all facilities assessed showed that only 50 percent of them had the ability to check blood glucose level, with just 52 percent capable of administering glucose for hypoglycaemia. On the other hand, the least service availabe was the ability to perform lumber puncture, at 7 percent, compared to administering of insulin for hypoglycaemia which scored 27 percent.
For service readiness, findings show that the mean availability of items was at a meagre 3 percent, while facilities with all items were just 1 percent of the total facilities assessed. The most available was glucose, while the antidote for opiate overdose was the least available.
Basic water and electricity
The assessment report discusses water and electricity under basic amenities. The report defines basic amenities as those facilities that comprise sanitation facilities; communication equipment; consultation rooms; improved water sources; power supply (grid or generator); emergency transportation; and computers with internet access. The assessment revealed that health facilities had a mean of 55 percent of basic amenities available during the day of the survey. It was also found that only 6 percent of the facilities had all the basic amenities during the day of the survey. Countrywide, 77 percent of the basic equipment was available, while only 24 percent of health facilities had all the basic equipment.
Management capacity and record keeping
The assessment also covered management and finance variables, whose findings were:
Management systems to support facility functionality, efficiency and accountability
The KHHFA report revealed that 67 percent of facilities reported existence of a core management team responsible for oversight of operations, while 52 percent of facilities had a core management team structure based on established norms and standards. Other findings revealed that 48 percent of facilities had formal systems for linking with community health centres. Furthermore, only 37 percent of facilities reported having put in place a routine system for including community representation for some aspects of management teamwork. Only 21 percent of the facilities had in place a functional community unit. This shows that not enough facilities have management systems to support functionality, efficiency and accountability.
Implementation of systems to improve accountability
The percentage of health facilities with systems to improve accountability was found to be generally low. Only 53 percent of health facilities had a system of determining clients’ opinions, while just 41 percent of facilities collected feedback from clients (patients) and discussed it with a view to improving management strategic decisions and policies. It was also found that only 18 percent of facilities had routine procedures for reviewing or reporting on client opinions.
Facility-level external supervision for management
Most facilities (94 percent) reported receiving external supervision from sub-county, county or national levels. However, only 59 percent of facilities had documentation from external supervisory visits received in the past three months before the assessment survey. There is a need for this gap in documentation of external supervision visits to be addressed through proper record keeping to facilitate evidence-based management.
Drug management systems
Drug management system was assessed in terms of the main source of pharmaceutical commodity supplies. It was revealed that 52 percent of health facilities reported that Kenya Medical Supplies Authority (KEMSA) was the routine pharmaceutical supplier. Other sources of pharmaceutical commodities were: private sources (25 percent), Mission for Essential Drugs and Supplies (MEDS) at 10 percent, local suppliers (9 percent), NGOs/donors (1 percent) and others (4 percent). Secondary and tertiary hospitals, as well as public primary hospitals, reported KEMSA to be their main source of pharmaceutical supplies at 58 percent and 89 percent, respectively.
On pharmaceutical commodity reporting systems, it was revealed that 73 percent of facilities kept records showing pharmacy commodities received, disbursed, and the balance brought forward. On the other hand, only 54 percent of facilities kept records indicating expired/unused drugs, and those removed from inventory. This low level of critical record keeping is a cause for concern as there is a high probability of mix-ups, leading to expired drugs being dispensed.
Additionally, only 33 percent of facilities kept pink Pharmacy and Poisons Board (PPB) forms for recording substandard quality stock, while just 32 percent of facilities kept the yellow PPB form, where adverse reactions are recorded. This low number of facilities that keep such important records points to a danger of substandard drugs getting into the system, as well as the fact that failing to monitor adverse reactions of drugs endangers clients’ health and safety.
Infection prevention and control (IPC) monitoring systems
According to the WHO, infection prevention and control is a scientific approach designed to prevent harm caused by infection to patients and health workers. It is anchored in infectious diseases, epidemiology, social science and health system strengthening. It is against this background that IPC has a unique role to play in the field of patient safety and quality universal health coverage. No country, regardless of the level of social economic development, can claim to be free from issues of healthcare-associated infections, hence the need for IPC programmes.
Countrywide, only 38 percent of health facilities had IPC guidelines. It was found that just 15 percent of facilities had guidelines for cleaning floors, counters and beds; as well as personnel trained in certified infection prevention and control courses. However, secondary and tertiary facilities had a remarkable 85 percent availability of IPC guidelines compared to dispensaries and medical clinics, which had 39 percent and 31 percent, respectively. Furthermore, 42 percent of facilities held multidisciplinary meetings, where IPC results were reviewed and only 24 percent of facilities had technical IPC committees. Clearly, health facilities with infection prevention and control monitoring indicators scored below average.
Systems for maintenance and repair
Health facilities which reported to undertake preventive and corrective maintenance for systems for maintenance and repair were below average at 43 percent, compared to only 10 percent of facilities that had corrective maintenance systems of medical equipment. The situation was rather grim at county level where only 13 out 47 counties, equivalent to 28 percent, reported having facilities with preventive and corrective maintenance for any system.
Facility use of information for management
The KHHFA assessed facilities’ use of information to enhance management, as follows:
Systems for ensuring quality of routine data
Most facilities scored below average (47 percent) in having routine and systematic processes in place for checking the quality of data used for reports. It was also revealed that just 10 percent of health facilities had developed policy guidelines for checking the quality of data utilised in official reports. Furthermore, health facilities with data improvement plans and teams were at a dismal 26 percent and 23 percent, respectively. Clearly, the country is not doing well to this end and requires a strategic approach to improve this system.
Evidence of use of service information and data for planning and management
The number of health facilities with a routine process for performance review grounded on data on facilities, outcomes, or patient feedback was low – at just 34 percent. Only 15 percent of health facilities in Kenya had evidence of using patient survey data, while just 14 percent had evidence of use of mortality data. While there was evidence of employee satisfaction survey, its implementation was poor, – with only 11 percent of facilities doing so. Utilisation of Health Management Information Systems (HMIS) reports by health facilities stood at 28 percent. It is noteworthy that facilities with evidence of use of workload data and special reports such as quality indicators was dismally low, at 26 percent and 24 percent, respectively.
Systems for monitoring indicators of the quality of inpatient care
Systems for monitoring indicators of the quality of inpatient care were assessed and it was found that 59 percent of facilities had a system for identifying and monitoring adverse events, for example, patient falls and infections. Furthermore, 73 percent of facilities reported having conducted reviews for some proportions of deaths, compared to 82 percent of facilities, which carried out routine case reviews for patients who were still alive for quality, and the possibility of improved services.
Additionally, facilities that monitored cases of fatality rates for any specific diagnoses were just 28 percent, while performance by type of facility was between 48 percent in secondary hospitals and tertiary facilities, and 17 percent in public primary hospitals. Performance of hospitals monitoring cases of fatality rates for every specific diagnoses was quite low at just 28 percent. Hospitals that monitored fatality rates for cancer were worryingly the least, at 5 percent, Tuberculosis was at 14 percent, HIV infected patients at 20 percent, lower respiratory tract infections at 21 percent and malaria at 22 percent. These findings call for an urgent national and county strategic approach to strive to achieve higher and acceptable levels of compliance.
Early warning management systems
Use of unique identifiers (patient IDs) was also assessed and it was revealed that nationally, 90 percent of hospitals were compliant. On the other hand, health facilities that utilised standardised forms or electronic data entry screens to comprise a complete medical record for each patient averaged 50 percent of the total assessed facilities. Some 33 percent of facilities used the same unique patient ID for the same patient over multiple years, while only 7 percent stocked out official patient medical records in the past six months before the date of the survey.
Accountability for user fees
A number of facilities reported charging user fees for any outpatient service (40 percent) compared with 16 percent charged for any inpatient service. It was also revealed that 35 percent of facilities posted outpatient services user fees anywhere within the facility to enable patients to see them, compared with 34 percent of inpatient facilities. Communication is critically important to inform clients of what service is payable and what is not as a way of facilitating UHC.
Financial accountability
Financial accountability was not good, with just 47 percent of facilities reporting having received an annual external audit of facility accounts, while 52 percent of facilities had a budgeted annual work plan for 2018/19. More than half of the health facilities did not have a facility to externally audit their accounts and this may expose such facilities to the risk of financial mismanagement.
Quality care and safety
Assessment of systems for quality of care was carried out based on a number of variables:
Quality Improvement (QI) teams: The assessment revealed that nationally, only 53 percent of health facilities had QI teams. Higher levels of health facilities were found to have more QI teams compared to lower level facilities. The report indicates that 95 percent of all secondary and tertiary hospitals had QI teams compared to 43 percent of both dispensaries and medical clinics. Some 86 percent of private/NGO/FBO primary hospitals and 66 percent of health centres had QI teams. The lower national average of facilities with QI teams (53 percent), as well as at dispensaries and medical clinics (43 percent), is a matter that needs to be addressed, if health quality care and safety has to be improved.
Budget for QI activities: The assessment found that countrywide, a dedicated budget line for QI activities was set aside in 42 percent of health facilities assessed. The assessment report also highlighted facilities with dedicated budget lines for QI, namely; 80 percent secondary and tertiary hospitals, 54 percent public primary hospitals, and 69 percent private/NGO/FBO primary hospitals. The low number of health facilities countrywide with a dedicated budget line of QI activities can hamper the operationalisation of QI teams, thus compromising provision of quality care and service.
Health workers continued professional development (CPD) system: It was found that 44 percent of all health facilities nationally had a system for regular (at least quarterly) committees on medical education to support professional career development of medical officers, nurses and clinical officers. Higher levels of facilities tended to have CPD systems in place. For example, CPD systems were available at 80 percent of all secondary and tertiary hospitals, 81 percent of public primary hospitals and 80 percent of private/NGO/FBO primary hospitals. At lower level facilities, 61 percent of health centres, 39 percent of dispensaries, and only 36 percent of medical clinics had CPD systems.
Adverse event reporting systems (AERS): These systems are important in identifying and monitoring adverse events such as patient falls and hospital-acquired infections. The systems were found in 40 percent of all health facilities with inpatient services countrywide. An analysis of the availability of the systems by the managing authority showed that 90 percent of secondary and tertiary hospitals had AERS systems in place, while only 34 percent of dispensaries and 24 percent of medical clinics had them. In addition, 54 percent of public primary hospitals and 78 percent of private/NGO/FBO primary hospitals had AERS systems. Notably, only 38 percent of government facilities, 57 percent of NGO/FBO facilities and a paltry 36 percent of private facilities had AERS in place.
Infection control monitoring systems: These are designed in adherence to the WHO’s Infection Prevention Control (IPC) guidelines. Through integrated strategies, IPC can stop the spread of antimicrobial resistance and outbreaks, thus enhancing quality of care in the context of UHC. The WHO estimates that 1 out of 10 patients get an infection while receiving healthcare, translating into millions of people around the world getting infected as they receive healthcare.
The KHHFA report 2018 revealed that only 30 percent of all health facilities countywide had infection control monitoring systems and that the tendency by health facilities to monitor adherence to IPC guidelines improved with the level of the health facility. Health facilities with infection control monitoring systems were as follows; 80 percent of secondary and tertiary hospitals, 61 percent of both public primary hospitals and private/NGO/FBO/primary hospitals, 37 percent of health centres and 23 percent of dispensaries. Notably, only 28 percent of government health facilities, 33 percent of NGO/FBO owned hospitals and 31 percent of privately-managed health facilities had infection monitoring systems in place.
Monitoring of quality of care at facility levels: This was assessed through an analysis of data from a number of variables, whose findings are presented as follows:
System for verification of health worker licences
Nationally, only 39 percent of all health facilities in Kenya reported that they routinely verified their health professionals’ licences and registration status. In secondary and tertiary hospitals and public primary hospitals, 70 percent and 43 percent, respectively, had a system of verification of health workers’ licences in place. Furthermore, 93 percent of private/NGO/FBO primary hospitals had this system in place. The public/government health facilities did not fare well in this regard, with only 23 percent of such facilities having a system of verification of health workers’ licences. Some 58 percent of NGO/FBO-owned facilities and 53 percent of private facilities reported having this system.
Process for performance review – based on data on facility services, outcomes, or patient feedback
Nationally, 49 percent of health facilities reviewed their performance based on feedback data or patient feedback. Majority of hospitals reported having a system in place, with 90 percent of secondary and tertiary hospitals, 74 percent of public primary hospitals, and 79 percent of private/NGO/FBO primary hospitals reporting. Only 58 percent of health centres, 47 percent of dispensaries and 42 percent of medical clinics had complied. Furthermore, just 51 percent of government/public health facilities and 53 percent of NGO/FBO-owned facilities reported having this system.
Supportive supervision system for health workers
The assessment revealed that 71 percent of health facilities countywide had received a supportive supervision visit in the past three months from the date of the assessment survey. Other facilities that received supervision visits were as follows; secondary and tertiary hospitals (85 percent), public primary hospitals (90 percent), private/NGO/FBO primary hospitals (83 percent), health centres (83 percent), dispensaries (82 percent) and medical clinics (49 percent). Public facilities appear to have received the highest number of visits at 85 percent), with NGO/FBO-based facilities at 76 percent, and private at 53 percent. There is room for improvement towards achieving close to 100 percent supportive supervision visits. The low percentages in private and NGO/FBO health facilities is a cause for concern and calls for improvement if quality healthcare is to be achieved.
Systems for including community representation on management committees
A system for inclusion of community representation on management committees was not widely practiced or implemented in Kenya. It was revealed that only 49 percent of health facilities had a system of community representation on management committees. This means that the community voice is not heard in 51 percent of the health facilities which did not have this system in place countrywide. This exclusion not only locks them out of decision-making processes but also from expressing their grievances and suggestions on the facilities.
A closer analysis of the findings on community representation further revealed that 78 percent of public primary hospitals had some level of community representation, followed by secondary and tertiary hospitals at 60 percent, and private/NGO/FBO primary hospitals at 46 percent. Community representation systems for health centres was at 62 percent, dispensaries at 67 percent, with the lowest being medical clinics at only 16 percent.
System for measuring patient experience of care
Overall, the survey revealed that 38 percent of facilities countrywide had a system of measuring patient experiences. Higher levels of health facilities had the system in place, with 90 percent of secondary and tertiary, 62 percent of public primary hospitals, 78 percent of private /NGO/FBO primary hospitals, and 51 percent of health centres reporting that they measured patient experiences. Dispensaries and medical clinics had 30 percent and 37 percent, respectively. Only 33 percent of public/government facilities had a system for measuring patient experience of care in place, while NGO and FBO owned, and privately owned facilities, had achieved just 48 percent and 42 percent, respectively, in implementing the system.
Inpatient mortality reviews
The assessment survey established that there was a marked disparity by the managing authorities in terms of inpatient mortality reviews, with 30 percent of private health facilities reporting availability of mortality and morbidity reviews against government facilities, which were at 43 percent, and NGO/FBO-owned facilities at 52 percent. While secondary and tertiary hospitals had fully conducted mortality reviews (100 percent), the proportion among primary hospitals and health centres with inpatient capacity was much lower at 69 percent and 34 percent, respectively.
Systematic monitoring on the use of medicine
According to the KHHFA report 2018, 51 percent of health facilities had put in place systematic monitoring of the use of medicine. Some 52 percent of government/public facilities, 54 percent of NGO/FBO-owned facilities and just 49 percent of privately owned health facilities systematically monitored the use of medicine. This low level of monitoring on the use of medicine is a safety concern that needs to be addressed to reduce the probability of Kenyans being exposed to otherwise avoidable health dangers. The findings also revealed that public hospitals tended to have a higher availability of systematic monitoring of use of medicine compared with primary healthcare facilities.
Facility adherence to standards
The survey sought to assess facility adherence to standards by considering various variables whose findings are:
Facility participation in external accreditation licensing
Only 24 percent of all health facilities countywide participated in an external accreditation licensing process, with government facilities being less likely to have done so. Just 17 percent of government facilities, compared to 30 percent of NGO/FBO facilities and 31 percent of private facilities, participated in external accreditation licensing. Overall, 80 percent of secondary and tertiary hospitals compared to 30 percent of health centres participated in external accreditation − pointing to the fact that higher level hospital facilities were more likely to participate in the process.
Proper disposal of sharps waste
Proper disposal of sharps waste is critically important because improper management of such materials can have a negative impact, either directly or indirectly, on medical staff, waste handlers, the community and the environment. The KHHFA report highlights that 70 percent of health facilities nationally had proper disposal of sharps waste. However, there were variations depending on the type of the facility (64 percent to 76 percent) and managing authority (65 percent to 77 percent). For example, 65 percent of government managed facilities, 72 percent of FBO/NGO facilities and 77 percent of private facilities had proper disposal of sharps waste. Despite this achievement, there is a need to put in place measures to move towards 100 percent proper disposal of such materials.
According to the WHO, children playing with used syringes and needles can get needle-stick injuries and become infected; stick injury of medical staff can be a source of infection; and stick injury can also lead to Hepatitis B and C, HIV and sepsis infections.
Pharmaceutical commodity storage conditions
The assessment report revealed that only 22 percent of health facilities countrywide had adequate pharmaceutical commodity storage conditions. There was widespread inadequate storage of pharmaceutical commodities at government facilities (31 percent). FBO/NGO-owned facilities had only 28 percent, while privately managed health facilities had just 10 percent adequacy levels. This scenario attests to the need for adequate pharmaceutical commodities storage conditions to ensure high quality up to expiration dates.
Vaccine storage conditions
Heath facilities with adequate vaccine storage conditions were found to be 77 percent of the facilities assessed. Some 79 percent of government-owned facilities and 69 percent of FBO/NGO-owned facilities had adequate storage for vaccines. On the other hand, 69 percent of privately-owned facilities had adequate storage. Higher level hospitals were found to have more adequate storage of vaccines, with 100 percent of secondary and tertiary hospitals, and 93 percent of public primary hospitals having adequate conditions. While 83 percent of health centres and 76 per cent of dispensaries had adequate storage, only 68 percent of medical clinics were reported to have this capability.
Outbreak preparedness plans
The majority of health facilities did not have disease outbreak preparedness plans. Nationally, only 39 percent of health facilities had outbreak preparedness plans. At hospital facilities, only 45 percent of secondary and tertiary hospitals, 11 percent of public primary hospitals, and 32 percent of private/FBO/NGO primary hospitals had such plans. This finding paints a grave state of preparedness in Kenya should there be a serious disease outbreak or epidemic.
Guidelines on identifying and managing drug use problems
Availability of guidelines for identifying and managing drug use problems were common among hospitals, with secondary and tertiary hospitals having scored 80 percent, public primary hospitals 70 percent, while private FBO/NGO hospitals scored 67 percent. However, only 39 percent of all health facilities had such guidelines. Countrywide, lower level health facilities were found to have scored below average, with health centres scoring 47 percent, dispensaries getting 41 percent and medical clinics scoring only 27 percent. Government, NGO/FBO managed, and privately managed facilities all scored below 50 percent.