- Open Access
Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya
© The Author(s). 2019
- Received: 13 December 2018
- Accepted: 22 April 2019
- Published: 7 May 2019
Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi’s equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya.
We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach.
Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date.
If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity.
- Health services
Health equity and universal health coverage (UHC) are fundamentally about fairness and justice [1, 2]. Kenya has long described the importance of promoting health equity within policy documents and has made considerable progress in reducing mortality rates among children and improving coverage of health services . More recently the attainment of UHC has been promoted as one of the four central pillars taken up by the president within the current government’s agenda . Yet wide disparities in health outcomes and uptake of services persist, disadvantaging those most vulnerable . In part as a response to citizen’s frustrations with the wide inequities between regions, Kenya devolved services (including health) in 2013. We know from global experience that while devolution brings with it expectations for improved equity, in practice it is a complex process, and outcomes can be unpredictable, potentially widening, rather than reducing, disparities [5–9]. Within Kenya, early study indicates that opportunities for local prioritisation and community involvement for equity in resources allocation, have not yet been harnessed .
Systematic disparities in access and use of healthcare services, and/or equity in health financing contribute to inequities in healthcare. While equity is implicit in universal health coverage (UHC), there is still a risk that poorer, less advantaged groups may be left behind, unless health systems maintain an adequate focus on the measurement of equity [11–13]. There is the need to consider whether UHC policies close, rather than widen disparities in use of health services and health outcomes, and whether the processes for planning and monitoring are implemented in a pro-equity manner .
UHC should provide “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access” . A simple classification of services as high, medium and low priority1 is recommended, with countries not yet having universal coverage for all high-priority services recommended to first expand those, waiting to expand low or medium priority services until there is already near universal coverage for all high-priority services . Although lack of agreement over what this means can create a barrier to decision-makers.
Evidence has consistently shown that disadvantaged groups have poorer survival chances and lower use of facility-based services [2, 4, 5]. Therefore, in order to “to achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access” (p.847 ). Within Kenya this has been interpreted as relating to improving access to national health insurance fund (NHIF), but for true UHC is to be achieved, it will require “the provision of needed, and good quality health services to the entire population, without the risk of financial ruin” (p.1175 ). Community health services have an important interface role to play in attaining UHC by involving and empowering of communities to change health-related beliefs, behaviours and improve access and uptake of health services .
Mapping supply and demand determinants with Tanahashi levels of coverage
Supply and Demand
Tanahashi levels of coverage
Supply side determinants of the health system (those aspects of the health system which relate to the production of healthcare).
• Availability coverage – The availability of resources such as health workers, health facilities, drugs determines the extent to which a service can be provided.
• Accessibility coverage – Defines the population who can use or access the service. A service has to be geographically accessible, located within reasonable reach of people who need it and financially affordable.
Demand side determinants (those aspects operating at individual, household or community level, which influence the ability of an individual to identify illness, and willingness to seek and use appropriate health care).
• Acceptability coverage – This domain defines the people who can access the service, are willing to use it and finds it acceptable for example in terms of costs, waiting time, beliefs.
• Contact coverage – These are people who have been in contact with the service provider and have utilised the service.
• Effectiveness coverage – The proportion of the population in need of an intervention that receive an effective intervention.
Funding sources in Kenya following devolution.
County governments receive funding from three possible sources
1) transfers from central government which comprise an equitable share allocated to all the 47 counties from national general revenue collections using a revenue allocation formula, conditional grants ring fenced for specific functions, and an equalization fund for the 14 previously marginalized counties
2) locally generated revenue
3) donor funding
The county government authorities now have responsibility for budget allocation of these funds and annual planning. These county authorities also hold responsibility for developing the five-year county integrated development plan (CIDP) and five-year county strategic plan for health; health service delivery for level one to three services (community, primary and county referral services); recruitment and management of health workers and coordination of partners.
We used a qualitative research methodology to explore inductively, the implications of devolution for equity, through generation of rich data by seeking to understand what equity means for those involved with decision-making and ‘how’ equity can be improved [22, 23]. This methodology gives “due emphasis to the meanings, experiences, and views of all the participants” (p. 43 ), to develop possible explanations and theories surrounding the implications of devolution for equity at multiple levels .
Key indices for study counties
Marginalised3/ not marginalised
(Headcount ratio)(Kenya National Bureau of Statistics 2014)
Live births in previous 5 years % delivered by skilled provider(Kenya National Bureau of Statistics et al. 2014)
% children age 12–23 months who are fully vaccinated(Kenya National Bureau of Statistics et al. 2014)
We adopted a framework approach to analysis in order to classify and organise data according to the key themes, concepts and emerging categories . This included an inductive aspect, which allowed meaning to emerge from the data through familiarisation with the data by reading and re-reading through transcripts . Following this a thematic framework was developed, which drew on understanding of the literature, the objectives of the interview, the themes within the data collection tool, experiences during field data collection and issues raised by the respondents themselves during interviews. NVivo 10 software was utilised to manage and code data. Following coding, data was charted to summarise findings while still retaining its context and essence, based on data from all ten counties and enabling analysis, according to Tanahashi’s themes: availability, affordability, acceptability, accessibility and quality of health services provided.
Quality assurance and ethical considerations
Qualitative data was recorded with participant’s consent and transcribed verbatim. Data collection continued until saturation was reached and data was triangulated between sources to minimise bias. Community and some health facility level respondents were interviewed by trained research assistants in Kiswahili or Kamba (depending on respondents’ preference). These interviews and discussions were translated to English, with a selection back-translated for quality checking. All participants were provided with information about the study and gave informed written consent. The research proposal was approved by Liverpool School of Tropical Medicine (Research Protocol 14.007 and Research Protocol 14.044) and Kenya Medical Research Institute (KEMRI) (Non-SSC Protocol 469). In addition, approval was received from the National Council for Science and Technology (NACOSTI) (NACOSTI/15/2058/4010).
“For a very long time in fact we looked at equity from the lens of financial access and geographical access and a lot of the efforts were targeting that and ignoring other aspects …But actually there is quite number of barriers to access which we haven’t focused on and the policies have been very silent on that.” National Respondent, Male11
“[Fairness means] they should get high quality health services that reach everyone at the right time.” CHV Team Leader, Female08
“Instead of being given finances to come and budget they (county government) were forced to take some equipment, that’s what happened. You were to take equipment and you do not have the personnel who is able to run them and you were given. So they are lying all everywhere with no use… it’s not good by the way because like us we were given the CT scan machines and we have no personnel.” County Non-Health Respondent, Female46
“I think under devolution, there is more equity, communities that were previously marginalized - I’m talking about Turkana, Mandera, Wajir, Garrisa, Moyale - are receiving unprecedented development, things that they never imagined they would get. There is also the equalization fund which is also meant for these historically marginalized areas which is helping them also.” National Respondent, Male10
“You know when you go to a county, and you find that county leadership decides okay we want a nice gate to our county hospital, and then you walk into the county hospital and there are no drugs. Then probably the workers have not been paid. What does that say? It’s because the, the leader wants to say ‘you see we know our hospital is shining’. So it may not necessarily be speaking to the needs.” National Respondent, Male07
In many cases expansion of infrastructure appears to have been entirely appropriate, particularly in formerly marginalised areas where there was a huge deficit and extremely limited geographic access to services. Many counties described investing in infrastructure for primary care, such as dispensaries and health centres which typically benefit poor populations more than rich. With county governments using their local knowledge of underserved areas to make more informed decisions regarding the location of new facilities.
Changing power structures since devolution were felt to have led to increased power held by politicians, rather than technical decision makers and health workers within the county. One of the challenges of this is the emphasis on visible curative services, rather than the less tangible (but essential) preventive services. Powerful political leaders were felt to accumulate more services, compared with less powerful leaders, regardless of need. Technical county level respondents at times felt that this had a negative impact on the level of equity within the county.
In many counties there were concerns raised, primarily by technical health decision-makers, that many of the health facilities constructed with the intention of improving availability of health services had not yet been staffed, equipped or added to the register to receive government drugs, supplies and funding. As a result, they remained non-functional and unable to provide effective health services to the population they were intended to benefit. A further threat looming, was seen to be the lack of future planning for these new facilities, with many health workers and health technical decision-makers across the counties highlighting that politicians and community simply do not appreciate the recurrent and maintenance costs needed for a health facility, potentially impeding functionality or quality of services provided and undermining future sustainability.
“So today you will find this group living in Kenya, tomorrow they have crossed the border to Uganda…, but you know you cannot find facility, health facility remains home. So we make sure that we get CHVs from those communities, so they move with these communities.” County Health Respondent, Male39
Lack of variation in the number of CHVs for low density areas or hilly terrain created challenges for the CHVs, particularly those in pastoralist and some agrarian counties, with some CHVs having to travel up to 20 km between homesteads. As a result, CHVs and community members agreed that CHVs did not visit homes which were far away as frequently as homes close to their own, due to the long distance and lack of transport. Respondents from two counties described having introduced a modified community health structure, which accommodated varied population densities and terrain to address these challenges.
“Following the free medical services; the work load has grown very, very high.” Health Worker, Male11
“Every area you go to, you are told drugs are not here [government health facility]. They prescribe and you go buy outside. This has made the cost of treatment higher and not affordable …Of course that tells you that only the people with resources will now be able to access services that are relevant. People who are wealthy will afford to pay in the private clinics. People who are poor will wait and seek alternatives, like going for traditional medicine or self-treatment, self-medication on the counter.” National Respondent, Male04
“The county they should be ready to fund for an outreach because some places … when it rains it’s like they have been cut off in terms of transport.” County Health Worker, Male03
“We normally have integrated outreach … we expect the County government to be filling those gaps and it is not forth coming so we have a very big problem. So we can say there are totally no access.” Sub-County Respondent, Male04
“The community is well mobilized … and you can see the number of deliveries has gone up. Our people don’t like coming to the hospital to deliver, but because this CHV is impacting, now they are able to come to the facility.” County Health Respondent, Female40
“They [CHVs] are able to reach out to them, in fact we are able to get some out especially the disabled, the children with disability that used to be hidden, and nowadays we can see them being brought forward.” Sub-County Respondent, Female10
Having health workers trained in sign language at primary health facilities was an identified gap. Two counties had started or were planning to train health workers in basic sign language, to improve access to services for deaf patients.
Many counties have invested in hospitals and ambulances in efforts to strengthen referral services, but we found limited evidence to suggest this increased equitable contact with services (particularly for non-maternal health-related emergencies). Patients still need to pay user fees for services provided at hospitals (excluding maternal health services). Although waiver schemes are in place in many counties, challenges with long delays in reimbursement and limited scope for the payment (covers hospital fees only, rather than transport and other opportunity costs) continue to create barriers to patients making contact to use these services. Referral costs varied between counties, with no consistent policy regarding payment for ambulance referral. In one county, ambulance services were available free of charge for maternal health related emergencies. However, any other emergency could not use the ambulance, as a result of which the patient and their family would be obliged to seek private transport to reach a hospital. The major hospitals which offered a breadth of services and more experienced health workers were typically centred in urban areas, rather than the more remote places. Those living in more remote areas, who were poor were felt to experience a double challenge in reaching secondary level care.
By contrast to the challenges experienced by the most poor or those living in remote places with accessing level three services provided at the hospital, community members generally felt that community health volunteers (CHVs) (where present) improve contact with health services at the household level and prioritise attending the homes of those who are ‘vulnerable’. CHVs were often described by community members and their supervisors as providing additional support for their most vulnerable neighbours out of their own pockets.
In contrast to this norm, a small minority of community members in the most remote areas, felt that the CHV prioritises providing services to those in the community who are richer – those with a ‘pot belly’ or who have a tin roofed house, because “he (CHV) will go to that person because he will get something there.” Male community FGD02. However, the majority of community members, even in remote areas agreed with the dominant view described above, that CHVs prioritise visiting those who are disadvantaged.
There was limited emphasis on building the quality of health services provided following devolution. A range of respondents highlighted the inequitable dual level system for health (which pre-dates devolution). Under this system those who are rich pay for quality private care and those who are poorer receive perceived lower quality government services. Health workers and community respondents raised concerns around the quality of services provided at government facilities as a result of lack of drugs and supplies, particularly following increased patient contact coverage with services since removal of user fees at dispensaries and health centres.
“I have a problem with the services the doctors give and I feel bad about it, because I came here one day and I was misdiagnosed. The quality of services in this health centre should be upgraded.” Male community FGD04
Our findings reveal that devolution has brought wide ranging implications for health equity, some positive such as the inclusion of poverty within the equitable share of funds received by counties from national level, with support for formerly marginalised areas. Other positive findings include: increased availability of primary health facilities, typically in formerly underserved areas; efforts in some counties to promote acceptability of health services among deaf patients by training health workers in sign language; improved accessibility to services at household level, particularly for those most marginalised, through CHV home visits. However, alongside these positive findings there are also negative implications emerging since devolution with heavy investment in hospital equipment and infrastructure, which many of the most poor patients continue to struggle to access and use. In addition, political wrangling within some counties was perceived to influence decisions . Further, lack of emphasis on quality, has in some cases undermined the provision of services, with newly constructed facilities remaining unfinished and therefore unable to provide effective services. Uneven investment in community health between counties, has led to varied scope for households to benefit from these services.
Influence of devolution on the supply side
Devolution has brought improvements for the supply side, by expanding the availability and geographic accessibility of health services across many counties. These improvements have been undermined to some extent by heavy investment in improving the availability of hospital services, which predominantly benefit the rich , compared with community health services, which promote access to services among those considered marginalised . In addition, insufficient emphasis to ensure that the required human resources and drugs and commodities accompany infrastructure, hinders the quality of these services. The medical equipment deal appears to be at odds with devolution, which specifies that county governments are responsible for the provision of services from level one to level three (and which therefore includes decisions about procurement (or not) of diagnostic equipment for use within county referral hospitals at level three) . It is also working against the recommendations for UHC, which ought first to prioritise those high priority services which are of benefit to all citizens, before contemplating low priority ones, which benefit a smaller minority of citizens . In the push to address geographic access, many counties have sought to build new health facilities and extend curative services, but public health and population measures such as promotive, preventive and rehabilitative services at community level, which are all necessary for universal health coverage have been neglected to varying degrees [15, 16]. This has previously been described in Indonesia, where public health services reportedly deteriorated following devolution, with reduced access among poorer populations [28, 29].
Investment in infrastructure and equipment have been focused across both primary health facilities and hospitals. While primary health care has previously been demonstrated to be pro-poor, public hospitals in Kenya have primarily been used by the rich, with the richest quintile benefiting from two thirds of all hospital outpatient services . Hospitals can quickly absorb vast amounts of money. In Kenya they have previously consumed 50% of the health budget . It is therefore crucial that hospital construction and refurbishment which will primarily benefit the rich, does not undermine community-based primary health care services which can benefit all. Emphasis on infrastructure over quality, as perceived by users, was previously demonstrated following decentralisation in Tanzania and Indonesia [30, 31]. There local leadership were poorly informed about health, lacking the understanding to recognise the benefits of public health services .
The combined effect of devolution and abolishing of user fees have implications for equity in maternal health care, where demand has increased, but quality has not and neither has awareness of entitlement. This creates a tension in different country contexts. Our findings reveal that removal of user fees increased use of health services, in keeping with previous study in Kenya . Gitobu et al. (2018) revealed that the number of deliveries in health facilities increased by 29.5% following implementation of the free maternal health services policy remaining consistent over the two year period following introduction of the policy . In keeping with findings from our study, Gitobu et al. (2018) highlighted concerns about diversion of the free maternal health care funds by county governments, with implications for the quality of services .
Continued user fees (for non- maternal health services) at hospitals, with lengthy waiver process which did not cover opportunity costs was felt to contribute towards the continued exclusion of the most poor from receiving these services. Frequent supply chain gaps meant that health service users (who should receive free services) still needed to buy drugs elsewhere as described previously in Kenya, following introduction of devolution reforms [33, 34], resulting in continued exclusion of the most poor from effective services. Although recent study has indicated that when counties managed to procure drugs, health facilities reported a better order fill-rate, compared with prior to devolution . The introduction of these policies at the same time as devolution has previously been recognised to have influenced their implementation, leading to compromised quality by operational challenges including delayed reimbursements at health facilities and exacerbation of existing weakness, including shortages of health workers and drugs and supplies . There have been many discussions about increasing enrolment in national health insurance fund (NHIF) in Kenya, as a pathway to improving access to health services. As a result the Kenyan government have extended the service package to include outpatient as well as inpatient services, and have introduced an NHIF subsidy programme to identify and provide subsidy for NHIF membership for the poorest households . However, as our study highlights, in order for patients to receive effective health services, any intervention to increase insurance coverage, must have a strong quality emphasis, to ensure that services covered under NHIF enrolment are of good quality and provide effective coverage.
Influence of devolution on the demand side
In order to attain universal health coverage, services must also be acceptable to the population if they are to be utilised. Demand-side barriers including cultural and religious barriers, decision-making and gender autonomy and access to knowledge and information about health and services must first be addressed and overcome if health services are to be used . Similar to other countries, devolved counties in Kenya have generally been slow to approach these barriers . As we have published elsewhere, a few counties in Kenya have introduced demand generation strategies, such as community health approaches to encourage appropriate use of health services. However, most counties have not yet addressed constraints to accessing services, such as the acceptability of skilled delivery through engaging with cultural and religious beliefs and different community perceptions of health workers . Community health approaches can address and reduce many of these barriers , alleviating and reducing the forces which reinforce exclusion and thereby helping to improve acceptability and use of services. When CHWs are adequately empowered there is opportunity for them to act as community advocates , playing a key interface role in mediating demand side factors for equity and responding to the unique opportunities afforded them as a consequence of their intermediary position between the health system and the community .
Quality was rarely described as a value for priority-setting and infrequently described as a priority which counties were seeking to address. Instead, quality gaps such as limited functionality of community health services, lack of consistent drug supply chain (in some counties), lack of funds to support supervisors were described. As a result of the perceived lack of quality at public health facilities a ‘rich-poor’ divide was evident. While this is not a new phenomenon since devolution in Kenya, county governments have so far demonstrated little commitment to improving the quality of health services at public health facilities. In fact some of the interventions introduced prior to devolution to promote quality, such as transferring funds directly from the national treasury to health facility bank accounts , have potentially been undermined as a result of the control of funds at county treasury level, leading to delayed and lower transfers to health facility bank accounts. If not addressed, this may lead to a widening divide between rich and poor patients, as occurred in Indonesia with rich patients attending private health facilities and poor patients attending public health facilities, where the service quality was perceived to be poor . Quality improvement need not be costly, rather approaches which empower local solutions to quality through dialogue, rewarding best practice and advocacy can bring quality improvements with a modest resource investment . With regards to community health services, supervision and the policy environment can affect the quality of community health services provided .
Use of the Tanahashi framework
We find value in using the model as a framework to consider qualitative findings surrounding the process and content of priorities from an equity perspective following the introduction of devolution.
Devolution in Kenya has brought varied implications for health equity as outlined through the availability, accessibility, acceptability, contact with and quality of services provided. To date much of the focus has been on improving the availability, and accessibility of health services, which are helping to improve health equity for many. Yet if Kenya is to achieve universal health coverage for all citizens, then county governments will need to go further by ensuring that actions are introduced which increase acceptability, use and effective coverage of quality services. Community health services can play a crucial role to meet both the supply and demand-side aspects of health equity.
Services should be grouped into priority classes using criteria such as cost-effectiveness, priority to the worse off and financial risk protection .
REACHOUT is an ambitious five year international research consortium aiming to generate knowledge to strengthen the performance of CHWs and other close-to-community (CTC) providers in promotional, preventive and curative primary health services in six low- and middle-income countries in rural and urban areas in Africa and Asia, including Kenya.
The authors gratefully acknowledge the policymakers, county health management team and sub-county health management team members, facility managers, community health extension workers, community health volunteers and community members who gave of their time to be interviewed and the qualitative research team, including Robinson Karuga.
This research work was supported by co-funding from the European Union Seventh Framework Programme ([FP7/2007–2013] [FP7/2007–2011]) under grant agreement number 306090 and was conducted in collaboration with the REACHOUT consortium. REACHOUT is an ambitious 5-year international research consortium aiming to generate knowledge to strengthen the performance of CHWs and other close-to-community providers in promotional, preventive and curative primary health services in low- and middle-income countries in rural and urban areas in Africa and Asia. Time for review, editing and responding to reviewers’ comments was funded through the UKRI GCRF Accountability for Informal Urban Equity Hub (also known as ARISE) which is a UKRI Collective Fund award, RC Grant reference: ES/S00811X/1. The ARISE Hub – Accountability and Responsiveness in Informal Settlements for Equity – is a research consortium, aiming to enhance accountability and improve the health and wellbeing of marginalised populations living in informal urban settlements in Kenya, Sierra Leone, Bangladesh. The contents are the responsibility of the authors and do not necessarily reflect the views of the European Union Seventh Framework Programme nor the Global Challenges Research Fund.
Availability of data and materials
The data supporting our findings are contained within the manuscript.
The idea for the study and its design was conceived by RM, MT, ST, TM and LO. Data coding and preliminary analysis was carried out by RM, with regular discussions with LO, MM, MT, TM, NM and ST through the data collection and analysis process. RM prepared the initial draft of this paper. All authors reviewed the draft manuscript and provided input to preparation of and approval for the final version of the report.
Ethics approval and consent to participate
The research proposal was approved by Liverpool School of Tropical Medicine (Research Protocol 14.007 and Research Protocol 14.044) and Kenya Medical Research Institute (KEMRI) (Non-SSC Protocol 469). In addition, approval was received from the National Council for Science and Technology (NACOSTI) (NACOSTI/15/2058/4010). Written informed consent was sought from and signed by all interviewed respondents.
Consent for publication
The manuscript has anonymised information to ensure confidentiality.
The authors declare that they have no competing interests.
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