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THE IMPACT OF DEVOLUTION ON HEALTH CARE
SYSTEMS: A CASE STUDY OF NAIROBI COUNTY
HEALTH FACILITIES
BY
TRUPHENA MAKONJO GIMOI
UNITED STATES INTERNATIONAL UNIVERSITY
SUMMER 2017
THE IMPACT OF DEVOLUTION ON HEALTH CARE
SYSTEMS: A CASE STUDY OF NAIROBI COUNTY
HEALTH FACILITIES
BY
TRUPHENA MAKONJO GIMOI
A Research Project Report Submitted to the Chandaria School of Business in Partial Fulfillment of the Requirements for the Degree
of Masters in Business Administration (MBA)
UNITED STATES INTERNATIONAL UNIVERSITY
SUMMER 2017
ii
STUDENTS DECLARATION
I, the undersigned, declare that this is my original work and has not submitted to any other college,
institution or university other than the United States international university in Nairobi for academic
credit.
Signed: _____________________ Date: ____________________________________
Truphena .M. Gimoi (ID638613)
This project has been presented for examination with my approval as the appointed supervisor.
Signed: _____________________ Date: ____________________________________
Timothy C. Okech, PhD
Signed: _____________________ Date: ____________________________________
Dean, Chandaria School of Business
iii
COPYRIGHT PAGE
Truphena Makonjo Gimoi © 2017
All rights reserved
iv
ABSTRACT
The purpose of this study was to analyze the impact of devolution on healthcare
systems. The study was guided by three research questions namely i) what is the
effect of devolution on health infrastructure? ii) What is the effect of devolution on
access to health services? and iii) what is the effect of devolution on health care
workforce? Stratified sampling technique was used to select respondents based on
cadres in order to have a sample population that is representative. They include
Pharmacists, clinicians, Nurses, medical officers, procurement officers and Hospital
Managers. The population of study was ninety-four public health facilities in Nairobi.
Data was collected using a structured questionnaire, with pilot conducted on a sample
of thirty respondents from Westland’s health facilities was used. Both descriptive and
inferential statistical methods were used to analyze the data. Whereas descriptive
statistics included frequency tables, charts and graphs, inferential statistics including
t-tests, regression and correlation analysis was used to determine relationships
between variables.
The study revealed that devolution had an improvement on health infrastructure.
Medical equipment was in good condition in most facilities and new equipment had
been acquired under the medical equipment scheme such as x-ray machines,
nebulizers, lab equipment among others. In terms of access, it was observed that most
health facilities served an average population of between 5000 to 10,000 people,
which shows a low reach out to the intended population which should be of 30,000
people. Also, of importance to note, was that most of the health facilities had
ambulances for use during emergency services, although inadequate funding for
medicines, equipment and maintenance of buildings was observed. Significant gaps
were also identified in the health care workforce where there was shortage of staff in
health facilities coupled with lack of motivation mechanisms put in place that led to
low productivity.
In conclusion there still exist significant gaps with health infrastructure, especially
need for specialized medical equipment, maintenance of the equipment and the
personnel to operate the equipment. Similarly, under access, there is need for wider
outreach to the population, need to address funding for medicines and other medical
supplies to avoid stock-outs and maintenance of buildings. There were also notable
gaps in health care workforce, with staff shortages in health facilities and staff who
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are demotivated. From the findings the study recommends that equipment should be
maintained in good working condition and counties should consider having
designated units for repair and maintenance of the equipment coupled with personnel
to do the repairs, also, allocate funding for purchase of specialized equipment. Other
recommendations include, allocate more funds for purchase of medicines and
maintenance of buildings, hiring of more workers to address the shortage problem
which can be done by emulating best practices where non-professional people are
hired and trained to offer non complicated procedures such as taking weights. Also,
county healthcare facilities should put in place motivation mechanisms such as risk
allowance, provision of bonuses and time-offs for their staff.
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ACKNOWLEDGEMENT
I am grateful to the almighty God for whom this study could not have been possible
I am greatly indebted to my supervisor Prof Timothy C. Okech for his valuable
guidance throughout the study. My special appreciation goes to my family and friends
for their motivation, prayers and encouragement during the study.
May God bless you all.
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DEDICATION
To my husband Richard Tilak, Son Kibet Kipchumba and daughter Chemutai Tilak
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TABLE OF CONTENT
STUDENTS DECLARATION ............................................................................................... ii
COPYRIGHT PAGE ………………………………………………......................................iii
ABSTRACT ........................................................................................................................... .v
ACKNOWLEDGEMENT …………………………………………………………………...vi
DEDICATION……………………………………………………………………………….vii
LIST OF ABBREVIATIONS ……………………………………………………………….xi
LIST OF TABLES…………………………………………………………………………...xi
LIST OF FIGURES ………………………………………………………………………..xiii
CHAPTER ONE ..................................................................................................................... 1
1.0 INTRODUCTION ...................................................................................................... 1
1.1 Background of the Problem........................................................................................ 1
1.2 Statement of the Problem ........................................................................................... 6
1.3 Purpose of the study ................................................................................................... 7
1.4 Research questions ..................................................................................................... 7
1.5 Importance of the study .............................................................................................. 7
1.6 Scope of the study ...................................................................................................... 8
1.7 Definition of terms ..................................................................................................... 8
1.8 Chapter summary ..................................................................................................... 10
CHAPTER TWO................................................................................................................... 11
2.0 LITERATURE REVIEW ......................................................................................... 11
2.1 Introduction .............................................................................................................. 11
2.2 Effect of devolution on health facility infrastructure ............................................... 11
2.3 The Effect of Devolution on Access to Health Services. ......................................... 16
2.4 Effect of Devolution on Health Care Work Force ................................................... 20
2.5 Chapter Summary ..................................................................................................... 24
ix
CHAPTER THREE ............................................................................................................... 25
3.0 RESEARCH DESIGN AND METHODOLOGY .................................................... 25
3.1 Introduction .............................................................................................................. 25
3.2 Research Design ....................................................................................................... 25
3.3 Population and Sampling Design ............................................................................. 26
3.4 Data Collection Methods .......................................................................................... 27
3.5 Research Procedures ................................................................................................ 28
3.6 Data Analysis Methods ............................................................................................ 28
3.7 Chapter Summary ..................................................................................................... 28
CHAPTER FOUR ................................................................................................................. 30
4.0 RESULTS AND FINDINGS ................................................................................... 30
4.1 Introduction .............................................................................................................. 30
4.2 Response Rate and General Information .................................................................. 30
4.3 The Effect of devolution on health Infrastructure .................................................... 34
4.4 The Effect of Devolution on Access to Health Services .......................................... 40
4.5 The Effect of Devolution on Health Care Workforce .............................................. 53
4.6 Chapter summary ..................................................................................................... 59
CHAPTER FIVE ................................................................................................................... 60
5.0 SUMMARY, DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS 60
5.1 Introduction .............................................................................................................. 60
5.2 Summary of findings ................................................................................................ 60
5.3 Discussion ................................................................................................................ 61
5.4 Conclusion................................................................................................................ 63
5.5 Recommendations .................................................................................................... 64
REFERENCES ...................................................................................................................... 66
APPENDICES ....................................................................................................................... 70
x
LIST OF ABBREVIATIONS
DHMT-District Health Management Team
DMOH-District Medical Officer of Health
GoK- Government of Kenya
HRH- Human Resources for Health
MoH- Ministry of Health
NGO- Non Governmental Organizations
SPSS- Stastistical Package for Social Sciences
SWAp- Sector-Wide Approach in Health
TA- Transition Authority
UHC- Universal Health Coverage
WHO- World Health Organization
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LIST OF TABLES
Table 1: Current status of health infrastructure….............................................................… 14
Table 2: Nairobi County Health Facilities…………………………………………………. 28
Table 4.1: Departments interviewed………………………………………………………. 32
Table 4.2: Position of respondents in the organization…………………………………..… 32
Table 4.3: The level of education of the respondents…………………………………..…… 33
Table 4.4: The gender of the respondents…………………………………………………. 33
Table 4.5: The age of the respondents…………………………………………………..….. 34
Table 4.6: The years of service in the organization……………………………………..….. 34
Table 4.7: Difference between gender and position held………………………………….. .34
Table 4.8: Independent samples test…………………………………………………….….. 35
Table 4.9: Clean toilets available for staff and patients………………………………... ….. 36
Table 4.10: Availability of protected placenta pit……………………………………… ….. 36
Table 4.11: Disposal of sharp wastes……………………………………………………….. 36
Table 4.12: Availability of a generator…………………………………………............ ….. .37
Table 4.13: Water supply………………………………………………………..............….. 37
Table 4.14: Communication Facilities……………………………………….…………..…. 38
Table 4.15: Email /internet facility……………………………………………................ …38
Table 4.16: New equipment…………………………………………………………….. . …39
Table 4.17: Transport used during emergencies………………………………………... . …40
Table 4.18: Correlation between budget for the year and state of medical equipment… ..... 41
Table 4.19: Transport used by patients referred from other facilities…………………... .... 42
Table 4.20: Correlation between catchment area and time taken to get to facility……… .. .44
Table 4.21: Correlation between source of funds and budget……………………………. .. 46
Table 4.22: Adequate funding allocated for medicine……………………………………... 47
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Table 4.22: Adequate funding allocated for equipment…………………………………..47
Table 4.23: Adequate funding allocated for maintaining buildings………………………47
Table 4.24: Designated unit for repair and maintenance of equipment…………………..48
Table 4.25: Unit for repair and maintenance predicts the state of medical equipment…...48
Table 4.26:Offer basic emergency obstetric care…………………………………………49
Table 4.27: Emergency obstetric care that require specialists……………………………50
Table 4.28: Free maternity services………………………………………………………50
Table 4.29:Labour ward…………………………………………………………………..50
Table 4.30: Offer routinely inpatient care………………………………………………...50
Table 4.31: Have beds for overnight observation………………………………………...51
Table 4.32: Number of staff………………………………………………………………55
Table 4.33: Adequately staffed…………………………………………………………...55
Table 4.34: Continual medical education…………………………………………………55
Table 4.36: Mechanisms used for staff motivation……………………………………….57
Table 4.37: Receive promotion …………………………………………………………..58
Table 4.38: Criteria for promotion………………………………………………………..58
Table 4.39: Correlation size of the catchment population and total number of staff…….60
xiii
LIST OF FIGURES
Figure 4.1: State of medical equipment…………………………………………………...39
Graph 4.1: New equipment bought since county government came into place…………..40
Figure 4.2: Catchment population………………………………………………………...42
Figure 4.3: How much time it takes patients to get to facility……………………………43
Figure 4.4: Source of funding…………………………………………………………….45
Figure 4.5: Budget for the year…………………………………………………………..46
Graph 4.2: Number of inpatient beds………………………………………………….....52
Figure 4.6: Condition of laboratory………………………………………………………53
Figure 4.7: Replenishment of medical supplies……………………………………….....53
Figure 4.8: Store audit…………………………………………………………………....54
Graph 4.3: Medical education received…………………………………………………..56
Figure 4.9: Frequency of Appraisals………………………………………………….......57
Graph 4.4: Areas of Improvement………………………………………………………...59
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CHAPTER ONE
1.0 INTRODUCTION
1.1 Background of the Problem
Devolution entails transfer of certain powers and responsibilities and resources from the
central government to popularly elected regional or local governments that are established
by law (Bosire, Cottrell Ghai & Pal Ghai, (2015). Devolution is the statutory delegation of
powers from the central government of a sovereign state to govern at a sub-national level,
such as a regional or local level. It is also a form of administrative decentralization or the
transfer of authority and responsibility from central to lower levels of government for a
range of public functions including health care (Williamson & Mulaki, 2015; Okech,
2017). Devolved territories have the power to make legislation relevant to the area
meaning that the units have clear and legally recognized geographical boundaries over
which they exercise authority and within which they perform their functions in their
respective jurisdictions (Okech, 2017). Worldwide, there has been a trend in the devolution
of authority in healthcare whereby the authority that was often sitting with one central
Ministry or Department of Health devolved over time (KPMG, 2015; Okech, 2016).
When governments devolve functions, they transfer authority for decision-making,
finance, and management to quasi-autonomous units with corporate status (World Bank,
2014). Depending upon the functions and authorities transferred, decentralization
processes can involve one or more categories (Okech, 2017).In Kenya, following the
promulgation of the new constitution in 2010, a devolved system of governance with two
levels of government - National and County government was created (Okech & Lelegwe,
2016; Okech, 2017). At national level, health leadership is provided by the Ministry of
Health (MOH) whose key mandates include development of national policy; provision of
technical support at all levels; monitoring quality and standards in health services
provision. Others include provision of guidelines on tariffs for health services, conducting
studies required for administrative or management purposes (Okech, 2017). The Ministry
is also mandated with the development of national policy that guides the recruitment,
placement, training and remuneration of all health workers in the country; monitoring
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quality and standards in health services provision, and the charges for the various services
by health care providers. Provision of necessary legal framework for ensuring a
comprehensive and people driven health care delivery is also the responsibility of the
Ministry of Health (GoK, 2010; Okech, 2016; Okech, 2017).
In a devolved system, local governments have clear and legally recognized geographical
boundaries over which they exercise authority and within which they perform public
functions (World Bank, 2012). Despite decades of strong advocacy for the decentralization
of health administration, health care systems decisions are taken in central divisions of the
ministries of health in most world economies including African countries. These decisions
are then conveyed top-down through the provincial (or regional) health administration to
the operational services at district level: hospitals, health centers and vertical programme
centers (Blaise & Kegels, 2004).
Since independence in 1963, centralization has been at the core of Kenyan governance,
with power concentrated in the capital. As a result, Kenya has been marked by spatial
inequalities during this period of time. It is against this backdrop that healthcare devolution
is taking place. Article 174 of the Kenya Constitution clearly articulates the rationale
behind devolution as, among other reasons, self-governance, economic development and
equitable sharing of national and local resources. Kenya’s health infrastructure includes the
national teaching hospital, provincial hospitals, district and sub district hospitals, health
centers, and dispensaries, as well as a host of other operators within the private, non-
governmental, and traditional sectors. The system is a hierarchical-pyramidal organization
comprising five levels, the lowest being the village dispensary and the Kenyatta National
Hospital at the apex (Wamai, 2009).
Centralized health systems have been criticized for regional and provincial discrepancies in
the health service distribution, disparities in resource allocations, and inequitable access to
quality health services. Over the past decade, Kenya has committed to reforms to
decentralize the country’s health management system, to increase decision-making power
for resource allocation and service delivery at the district and facility levels and to allow
for greater community involvement in health management. Through gradual reforms
outlined in the two Health Sector Strategic Plans, District Health Management Boards and
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District Health Management Teams (DHMTs) have taken on responsibilities for facility-
level operations within their districts (Ndayi et al., 2009).
The Kenya Health Policy Framework has been the basis for the health development agenda
in Kenya since 1994. The framework emphasizes “quality health care that is acceptable,
affordable and accessible to all.” The implementation of this framework was divided into
two five-year strategic plans: the National Health Sector Strategic Plan 1 (MOH 1999) and
the National Health Sector Strategic Plan II (MOH 2005). The objectives of the National
Health Sector Strategic Plan I (NHSSP I, 1999-2004) were to: strengthen governance,
improve resource allocation, decentralize health services and management, shift resources
from curative to preventive and Primary Health Care services, provide autonomy to
provincial and national hospitals and enhance collaboration with stakeholders under a
Sector-Wide Approach in Health (SWAp) modality among others(KHSA, 2010).
The mandate for supervision, formulation of policies, establishment and enforcement of
standards, and mobilization of resources for health care rests with the Ministry of Health.
Lower levels of administrations called districts, were responsible for delivering health
services and implementing health programs. Under the decentralization strategy, districts
form the central pillars of the public health system. Management of healthcare at the
district level is headed by a District Medical Officer of Health (DMOH) appointed by the
Ministry of Health. The DMOH is supported by a District Health Management Board
(DHMB) comprising officials appointed by the MOH and from local areas, and a
professional unit, the District Health Management Team (DHMT). The DHMT prepares
technical advisories and the District Health Plan in consultation with local health actors
and the DHMB.The provinces and districts vary in geographical size and population, as
well as overall health and socio-economic indicators (Wamai, 2009).
In a renewed effort to improve health service delivery, the Ministry of Health and
stakeholders reviewed the NHSSP-I service delivery system in order to devise a new
strategy for making it more effective and accessible to as many people as possible.
(NHSSP II 2005 – 2010) was designed to reduce health inequalities and to reverse the
downward trend in health-related impact and outcome indicators that had been noted
during the implementation of the NHSSP-I. Its strategic objectives were to: increase
equitable access to health services, improve quality and the responsiveness of services in
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the sector, enhance the regulatory capacity of MOH, improve the efficiency and
effectiveness of service delivery and foster partnerships in improving health and improve
the financing of the health sector. Key innovations of the NHSSP II include the definition
of the Kenya Essential Package for Health (KEPH) and the inclusion of the community
level as part of the service delivery units (GoK, 2010).
The objectives of the KEPH are fundamental to the overall policy objectives of NHSSP II.
Specifically, KEPH intends to: Increase access to health services by targeting part of its
interventions at the community level and at poor deprived areas and groups (poor districts
and sub-districts, pastoralists): Integrate the different programmes towards the client;
Enhance the promotion of individual and community health; Improve quality of service
delivery by improving the responsiveness of health workers and changing their prevailing
attitudes towards clients (GoK, 2010).
The Government of Kenya developed Vision 2030 as its new long-term development plan
for the country. The aim of the Kenya Vision 2030 is to create “a globally competitive and
prosperous country with a high quality of life by 2030” through transforming the country
from a third world country into an industrialized, middle income country. To improve the
overall livelihoods of Kenyans, the country aims to provide an efficient integrated and high
quality affordable health care system. Priority will be given to prevented care at
community and household level, through a decentralized national health-care system. With
devolution of funds and decision-making to county level, the Ministry headquarters will
then concentrate on policy and research issues. With the support of the private sector,
Kenya also intends to become the regional provider of choice for highly-specialized health
care, thus opening Kenya to “health tourism”. Improved access to health care for all will
come through: provision of a robust health infrastructure network countrywide; improving
the quality of health service delivery to the highest standards; promotion of partnerships
with the private sector; providing access to those excluded from health care for financial or
other reasons. The country recognizes that achieving the development goals outlined in
Vision 2030 will require increasing productivity. The health sector is expected to play a
critical supportive role in maintaining a healthy workforce which is necessary for the
increased labour production that Kenya requires in order to match its global competitors.
Health is, therefore, one of the key components in delivering the social pillar ‘Investing in
the People of Kenya’ for the Vision 2030 (GoK, 2008). In August 2010, Kenya adopted a
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new constitution that introduced a new governance framework with a national government
and 47 counties. This was a radical departure from the highly centralized form of
governance that had been in place since independence, but resulted in political and
economic disempowerment and unequal distribution of resources (World Bank, 2012).
The highly centralized government system also led to the weak, unresponsive, inefficient,
and inequitable distribution of health services in the country (Ndavi et al., 2009). It is
expected that a devolved health system will improve efficiency, stimulate innovation,
improve access to and equity of services, and promote accountability and transparency in
service delivery (Bossert, 1998). However, the complexity of Kenya’s devolution
framework has generated concern that services could be disrupted if the transition is
managed poorly.
Under the new framework, responsibility for health service delivery is assigned to the
counties while policy, national referral hospitals, and capacity building are the national
government’s responsibility (Constitution of Kenya [COK], 2010).The framework for the
transfer of these functions is in the Transition to Devolved Government Act, 2012. The
health service delivery function was formally transferred to counties on August 9, 2013,
and one-third of the total devolved budget of Ksh 210 billion was earmarked for health in
the 2013/2014 budget following the transfer Barker, Mulaki, Mwai, &Dutta (2014).
The objectives of devolution, include the following: The promotion of democracy and
accountability in delivery of healthcare; Fostering of seamless service delivery during and
after the transition period; Facilitating powers of self-governance to the people and
enhancing their participation in making decisions on matters of health affecting them;
Recognizing the right of communities to manage their own health affairs and to further
their development; Protection and promotion of the health interests and rights of minorities
and marginalized communities, including informal settlements such as slum dwellers and
under-served populations; Promotion of social and economic development and the
provision of proximate, easily accessible health services throughout Kenya; Ensuring
equitable sharing of national and local resources targeting health delivery throughout
Kenya; Enhancing capacities of the two levels of governments to effectively deliver health
services in accordance with their respective mandates; Facilitating the decentralization of
state organs responsible for health, their functions and services from the Capital of Kenya
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;Enhancing checks and balances and the separation of powers between the two levels of
government in delivery of health care (GoK, 2014).
The two levels of governments, have specific functions assigned to them which are as
follows: National government: leadership of health policy development; management of
national referral health facilities; capacity building and technical assistance to counties;
and consumer protection, including the development of norms, standards and guidelines.
County governments: responsible for county health services, including county health
facilities and pharmacies; ambulance services; promotion of primary healthcare; licensing
and control of undertakings that sell food to the public; cemeteries, funeral parlors and
crematoria; and refuse removal, refuse dumps, and solid waste disposal(COK, 2010).
1.2 Statement of the Problem
The Constitution of Kenya was formally promulgated into law on 27th August 2010. The
new constitution introduced major changes in the country’s governance framework. A key
departure from the earlier system of governance is the shift from a highly centralized to a
decentralized governance framework, comprising of two levels of government the national
government and 47 county governments. Previously, the Executive, through the President
and the Cabinet, exercised significant political, administrative and fiscal power control
over both the national and sub-national governments. This changed with the establishment
of the county governments. Devolution as envisaged in the Constitution of Kenya provides
for sharing of political, administrative and fiscal responsibilities between the national and
the county governments. It is the assignment of these three dimensions of power that
determine the level of devolution (Mwenda, 2010).
Barker et al (2014) found that devolution came with fears of disruption of services that are
largely linked with concerns about the counties’ readiness to deliver services. The
Transition Authority (TA) set specific timelines and criteria for the assessment of county
preparedness to take up devolved functions. The criteria are however considered to be
generic, making it difficult to determine whether counties are ready to offer the health
services under their ambit. In addition, political pressure from the newly elected county
governments led to a bulk transfer of functions, irrespective of the counties’ level of
preparedness.
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Considering that a strong, efficient, well-run health system and a sufficient capacity of
welltrained, motivated health workers among other pillars are important in realizing
universal coverage, the paper aimed to fill the knowledge gap of the country’s health
infrastructure, access and healthcare workforce and how these impact on health care
delivery with devolution.
1.3 Purpose of the study
The purpose of this study was to analyze the impact of devolution on health care
systemsby health facilities in Nairobi County.
1.4 Research Questions
The study was guided by the following research questions:
1.4.1 What is the effect of devolution on health infrastructure?
1.4.2 What is the effect of devolution on access to health services?
1.4.3 What is the effect of devolution on health care workforce?
1.5 Importance of the study
Due to the increasing need to meet the millennium development goals on health, the study
will benefit the following stakeholders among others:
1.5.1 National Government
National government has stated intentions of improving health care. The Kenya Health
Policy 2014–2030, goal is attainment of the highest standard of health in a manner
responsive to the needs of the Kenya population. The study will help measure the goal and
assess areas of improvement.
1.5.2 County government
The primary outcomes that are common decentralization goals that include improved
service delivery (efficiency, equity,), improved governance (deeper and more inclusive),
poverty reduction, improved livelihoods, and increased stability. The study will enlighten
the county government on whether it has met its primary outcome and areas that need
improvement with regard to county health facilities. If these outcomes are met it will
enhance governance and well-being and reduce conflict.
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1.5.3 Communities
The study will edify communities to hold leaders and those in charge of implementation
accountable, by improving public service delivery through efficient resource allocation,
enhancing accountability, reducing corruption and improving cost recovery. It will also
give insight on progress of devolution in counties and communities can express a voice
that may put pressure on institutions to take account of failings in accountability.
1.5.4 Management and staff of Health facilities
The study will be important to the management and staff of health facilities because it aims
to create awareness to the areas that need improved delivery and ensure primary health
care to the people is improved.
1.5.5 Academic Research
The study will make a significant contribution to the growing body of research on the
impact of devolution on development.
1.6 Scope of the study
The study focused on Nairobi county health facilities. Respondents selected were
Pharmacists, clinicians, Nurses, medical officers, procurement officers and Hospital
Managers. The study began in January 2016 with the introduction, literature review,
research design and methodology and second part of data collection results and findings,
summary discussions, conclusions and recommendation was completed in May 2017.
1.7 Definition of terms
1.7.1 Devolution
Is the transfer of certain powers and responsibilities and resources from the central
government to popularly elected regional or local governments that are established by law
(Bosire, CottrellGhai and PalGhai, 2015).
1.7.2 Decentralization
Decentralization involves assigning public functions, including a general mandate to
promote local well-being, to local governments, along with systems and resources needed
to support specific goals (Bosi, Loffler &Smoke, 2013).
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1.7.3 Political decentralization
This involves the transfer of political authority to the local level through the establishment
of sub-national governments as well as electoral and political party reforms.
1.7.4 Administrative decentralization
This refers to the full or partial transfer of functional responsibilities to the sub-national
units of governance. Functions that are typically transferred to the sub-national units
include health care services, garbage collection, among others.
1.7.5 Fiscal decentralization
This refers to the transfer of financial authority to the sub-national governments by
reducing the conditions on the intergovernmental fiscal transfer of resources and granting
sub-national units greater authority to generate their own revenue (Mwenda, 2010)
1.7.6 Primary health care
Is defined as essential health care; based on practical, scientifically sound, and socially
acceptable method and technology; universally accessible to all in the community through
their full participation; at an affordable cost; and geared toward self-reliance and self-
determination (WHO &UNICEF, 1978).
1.7.7 De-concentration
De-concentration is transfer of administrative responsibilities to nonelected central
government officials at the regional offices.
1.7.8 Delegation
Transfer of managerial responsibility to a unit outside the usual central government
structure (Mwenda, 2010).
1.7.9 Health infrastructure
Relates to all the physical infrastructure, non-medical equipment, transport, and technology
infrastructure (including ICT) required for effective delivery of services (GoK, 2014)
1.7.10 Health care services
The prevention and management of disease, illness, injury, and other physical and mental
impairments in individuals delivered by healthcare professionals through the healthcare
10
system; they can either be routine health services or emergency health services (KHP,
2014-2030).
1.7.11 Health care work force
The workforce that delivers the defined healthcare services. The workforce includes all
those whose prime responsibility is the provision of healthcare services, irrespective of
their organizational base (public or non-public) (GoK, 2014).
1.7.12 Health care system
The mechanism to deliver high-quality healthcare services to all people when and where
they need them (GoK, 2014).
1.8 Chapter summary
This chapter has introduced the problem and the purpose of the study. The following areas
of discussion have been included; Background of the problem; statement of the problem;
Purpose of the study; Research Questions; Importance of the Study; Scope of the study and
definition of terms.Chapter two presents a review of the literature that is relevant to the
objectives of the study, while chapter three present the research methodology used.
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CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 Introduction
This chapter provides literature on devolution of health care. It also presents general
assessment ondevolution of health care with both local and international experiences.This
is organized based on research questions as outlined in chapter one.
2.2 Effect of devolution on health facility infrastructure
A country’s healthcare system may be analyzed on the basis of the healthcare
infrastructure, the players and their roles, and financing mechanisms. Each of these
features of the system in Kenya and their utilization are discussed.
2.2.1 Health Infrastructure
To realize universal coverage, a strong, efficient, well-run health system is necessary
(WHO, 2010). This in turn requires a robust health infrastructure in terms physical
infrastructure, medical equipment, communication and ICT, Transportation. Kenya’s
health care provision and implementation infrastructure include the national teaching
hospital, provincial hospitals, district and sub-district hospitals, health centers, and
dispensaries, as well as a host of other operators within the private, non-governmental, and
traditional/informal sectors. The system is a hierarchical-pyramidal organization
comprising five levels, the lowest being the village dispensary with Kenyatta National
Hospital (KNH) at the apex. The health sector requires establishment of an effective
organization and management system to deliver on the KEPH.
The many years of neglect caused by budgetary insufficiencies has reduced most facilities
to a sorry state that requires rehabilitation before a maintenance programme can be
instituted. Some of Kenya’s health facilities lack adequate premises for priority
interventions, such as delivery rooms, maternity, laboratories, theatres, etc. Public health
technicians who were trained to maintain physical infrastructure are not used for that
purpose. Similarly, because of low budgetary allocations to health, the few available
12
resources have been fully charged to pharmaceutical and non-pharmaceutical commodities.
As a result, equipment has not been replaced for a long period, compromising the quality
of care provided. Staff skilled in maintenance are rarely available at the district levels and
below. Where they exist, they are not supported by the necessary tools, consumables or
financial resources. General maintenance capacity has therefore been eroded over the
years. Keeping the health infrastructure and the equipment in good condition would
undoubtedly change the public’s perception of good quality care and this in turn would
encourage people to use the available health services (GoK, 2005).
With establishment of Counties, the National level prioritize establishment of a minimum
number of health facilities, based on the expected services as defined in the KEPH.
According to the most recent health management information system (HMIS) data, there
are over 5,000 health facilities across the country operated by three owner systems, with
the government running 41% of the facilities, non-governmental organizations (NGOs)
15%, and private businesses 43%. The government owns most of the hospitals, health
centers, and dispensaries, while clinics and nursing homes are entirely in the hands of the
private sector. Health facilities are unevenly distributed across the country. For instance,
the best-off Central Kenya has about twice the number of facilities per population as the
worst-off provinces (Nyanza and Western). Central, Coast, and Eastern regions have better
ratios than the national average. On the other hand, Nyanza has a higher number of
hospital beds and cots per 100,000 population than Central. Northeastern and Eastern
regions have the worst ratios of hospital beds and cots per 100,000 population, while Coast
has the best (144, 145 and 274, respectively). Because of their relatively small
geographical sizes, Nairobi followed by Central has the minimal distance to a health
facility. (Wamai, 2004; MoH, 2010; MoH, 2015).
The available infrastructure has however continued to impact negatively on the care as
well as the ability to retain some key health personnel especially, specialized health
workers in the public service. Cases where for instance specialized doctors complained of
underutilization of their skills have been experienced with many opting to join private
practice or resigning to pursue further studies. If the situation is not addressed, in the end,
patients are likely to be left with no option but to either seek services of less qualified
health personnel or providers or alternative health care services whose quality may not be
guaranteed. Worse, others may seek services from private facilities which may be
13
relatively expensive thereby negating the expected gains of financial risk protection
currently being pursued under the enhanced National Hospital (Okech, 2016).
2.2.2 Current Status of health infrastructure
Many primary care facilities are not offering comprehensive package of primary care
services. Facility investments not matched with other investments (HRH, commodities,
etc.), affecting functionality after completion of investments. Limited investment in
maintenance of physical infrastructure ongoing supervision process monitoring
maintenance of physical infrastructure in hospitals.
Infrastructure investment focus has been on establishment of 201 model health Centre’s
under the economic stimulus package while more than 80 hospital projects are at various
stages of completion. There are, however, significant challenges particularly in relation to
equity in distribution of infrastructure, as shown in the Table 1
14
Table 3: Current status of health infrastructure
Area
Current Status
Physical
infrastructure
Significant ongoing projects, focusing on establishment
of 201 model health Centre’s, and expansion of hospital
infrastructure in 80 hospitals
Many primary care facilities not offering comprehensive
package of primary care services
Facility investments not matched with other investments
(HRH, commodities, etc.), leading affecting functionality
after completion of investments
Limited investment in maintenance of physical
infrastructure – ongoing supervision process monitoring
maintenance of physical infrastructure in hospitals
Communication
and ICT equipment
ICT equipment supplied to all public / FBO facilities
Communication equipment (telephones) available in all
hospitals
Radio equipment provided to all facilities in Arid / Semi-
Arid areas of the Country
Limited investment in maintenance of communication
equipment
Medical equipment
Investments in medical equipment ongoing in selected
hospitals
Lack of comprehensive, coordinated investment, with gaps
in some facilities still existent
Limited investment in maintenance of medical equipment
Transport Purchase of ambulances ongoing, at hospitals, and model
Health Centres
Still significant gaps in utility vehicle availability (some
ambulances also used as utility vehicles as a result)
MOH undertaking some measures to enhance transport
possibilities in the sector such as: outsourcing of certain
activities to the private sector, e.g. courier companies to
collect/deliver stocks/specimens, taxi companies for
referral in very rural areas with appropriate reimbursement
and ambulances for bigger hospitals
Limited maintenance investment
Source: KHSSP, 2013-2017
2.2.3 Health Care Financing System
The health sector in Kenya relies on several sources of funding: public (government),
private firms, households and donors (including faith based organizations and NGOs) as
well as health insurance schemes. Consumers are the largest contributors, representing
15
approximately 35.9 percent, followed by the government of Kenya and donors at 30
percent each. Over the past few years, government financing as a percentage of GDP has
been consistent at slightly above four percent. As a signatory to the 2001 Abuja
Declaration, Kenya committed to allocating at least 15 percent of its national budget to
health. Not only is Kenya spending a relatively low amount as a percentage of GDP on
healthcare, but the allocation of funds to public facilities has been uneven. According to a
2011 Healthy Action report, secondary and tertiary facilities have historically been
allocated 70 percent of the health budget. The same report notes that allocation of funds to
primary care facilities has been “poor” − this despite the significant role these facilities
play as the first point of contact in the provision of healthcare services (KPMG, 2015)
The share of government spending in the government budget depicts general
underfinancing of publicly provided for services, even though for some services especially
for non-communicable diseases, the gap is bridged by donors (Bultman, 2014; P4H, 2014).
In the Health Financing Strategy of 2010, the government emphasized social health
protection to all Kenyans by introducing social solidarity mechanisms founded on
complementary principles of social health insurance and tax financing for purposes of
financial protection of the poor and other vulnerable groups. In order to achieve the set
objectives, the government reiterated its commitment to amend the NHIF Act for purposes
of enhancing access, and broadening benefit package. In the new constitution promulgated
in 2010, the government provided the necessary legal framework for ensuring a
comprehensive and people driven health care delivery aimed at enhancing access to quality
and affordable health care (Okech & Lelegwe, 2016).
Recent initiatives of “Beyond Zero Tolerance” campaign for expectant mothers, children
and breast cancer are some of the latest efforts towards UHC. This has seen many
stakeholders pull resources towards the initiatives although there are still no reliable
statistics to inform policy dialogue on the pack of the initiatives. Whereas this is positive
step in the right direction, there is lack of policy to support the initiative to ensure
sustainability in the event of political regime change, which is undoubtedly expected in a
democratic society (Okech & Lelegwe, 2016).Unfortunately, limitations in implementing
an overall healthcare financing strategy has hindered effective planning, budgeting and
provision of health services. The health system has also struggled with stagnant or
16
declining budgets for health, system inefficiencies, persistently poor service quality and
lack of equity (Nyakundi, Teti, Akimala, Njoya, Brucker, Nderitu & Changwony, 2011).
Future planning needs to recognize that “reversing the trends” cannot be achieved by the
government health sector alone. Active involvement and partnership with other
stakeholders in the provision of care should be intensified. The goal should be a
functioning health system that relies upon collaboration and partnership among all
stakeholders, and whose policies and services have an impact on health outcomes. The
system should encompass a sector-wide approach and emphasize flexibility for rapid
disbursement and constant monitoring of budgetary resources.
‘Health Financing: The Case of RH/FP in Kenya’ recognizes that the State budget is the
most concrete declaration of a government’s national priorities. Budgets express
government commitment to a policy and indicate the level of priority assigned to it. It is
hoped that improved budget transparency will increase public engagement in the budget
process. This will in turn enhance pro-poor budget policies, allocations and outcomes,
(Nyakundi et al., 2011).
2.2.4 Challenges of Funding
Kenya faces several key challenges in health financing. First, access to services for
individuals and households is fragmented by coverage scheme, while the poor and
vulnerable are largely excluded. Second, the fragmentation of health financing schemes
also brings inefficiencies in service provision and investments. Third, a diverse set of
challenges exist that are related to health systems and public governance issues; key among
these are the lack of an effective quality assurance mechanism and ineffective corporate
governance and accountability mechanisms, which has led to a trust-deficit in Kenyan
health financing institutions. All areas need to be addressed urgently to make significant
progress towards Universal Health Coverage (UHC) (Bultman, 2014).
2.3 The Effect of Devolution on Access to Health Services.
Universal health coverage ensures that all people use the promotive, preventive, curative,
rehabilitative and palliative health services they need, of sufficient quality to be effective,
while also ensuring that the use of these services does not expose the user to financial
hardship has continued to dominate debate in health care (WHO, 2010). This embodies
three related objectives namely i) equity in access to health services so that those who need
17
the services should get them, not only those who can pay for them; ii) that the quality of
health services is good enough to improve the health of those receiving services; and
finally iii) financial risk protection which aims at ensuring that the cost of care does not put
people at risk of financial hardship (WHO, 2010)
Approximately 78 percent of Kenyans live in rural areas, yet a disproportionate share of
healthcare facilities are located in urban areas. Those in rural areas often have to travel
long distances, often on foot, to seek care. According to the World Bank, the index of
access to health services (measuring the share of newborns delivered at a health facility) in
Kenya, speaks volumes to this disparity. For example, over eight in ten children born in
Kirinyaga County, which is located in the central part of the country, are delivered in a
health facility. In Wajir, which is located in one of the most remote and marginalized
regions of the country, one child in twenty is born in a health facility (KPMG, 2013)
2.3.1 Access to Health Services in Kenya – Challenges in Risk Pooling
Financial access to health care services is a serious problem in Kenya. While average total
health expenditure (THE) per Kenyan at USD 42.2 in 2009/10 was sufficient to buy a basic
package of essential health services, there is strong variation around this mean. Out-of-
pocket spending was 25% of THE, showing that many Kenyans cannot rely on equitable
pre-paid financing mechanisms (MOH: NHA 2009/10). In fact, nearly 15% of Kenyans
spent more than 40% of non-food expenditure on health care. Health care is thus a major
source of financial distress for Kenyans. The small share of the health sector in the
Government budget (in 2009/10 only 4.6%) points to a general underfinancing of publicly
provided services, even though for some services (especially HIV/AIDS and Malaria)
some of the gap is made up by spending by development partners (MOH). This is related
to the co-existence of several different coverage schemes. The main ones among these are
the GOK free-care initiatives at primary health care facilities (dispensaries and health
centres) and for free maternal care (esp. deliveries) at higher levels, GOK subsidized
access for other care at referral levels, the National Hospital Insurance Fund (NHIF), as
well as Private Health Insurance (PHI). Some small Community Based Health Insurance
also exists. The existing schemes are isolated and are not connected through financial or
risk equalization mechanisms (P4H, 2014)
18
In 2013, the government announced the abolished user fees at primary health care facilities
and introduced free maternal health care services in public health facilities. This initiative
may be considered a populist policy meant to enhance access to quality care, especially the
poor and other vulnerable groups, its implementation was technically unattainable. The
concern was that at the time, the initiative lacked technical and necessary legal and
operational policies. Technical input to inform the policy initiative is necessary otherwise
the intended objectives may remain unattainable. For instance, following the policy
pronouncement, cases of delays in the disbursement of funds to counties have been
common with a few opting for bank overdrafts to meet operational expenses
notwithstanding the embedded charges. As noted earlier, a system for financing health
services is pivotal in UHC and if not carefully addressed, will negate the realization of
UHC. Cases of stock outs of drugs and other medical supplies, poor maintenance of
equipment, lack of transport, and medical facilities have continued to be experienced in
many public health facilities countrywide (Okech & Lelegwe, 2016).
Access to health services is very unequal and the poor are currently financially excluded
from access to many services. Devolution adds to the complexity, as Counties are now
expected to finance health service provision for primary and secondary care services from
their block grant allocation. Access to publicly provided services (the “free care” and
subsidized / “co-payment categories”) therefore depends on the budget allocations at
County-level, which further fragments financing of health services and hinders equal
access to care(Bultman, 2014).
2.3.2 Improving Access to Kenya Essential Package for Health (KEPH)
According to the Kenya Health Sector Strategic and Investment Plan (KHSSP), July2013-
June 2017 access is a measure of the ability of a person/community to receive available
services. It is a pre- requisite to high utilization of health services as it brings services
closer to the people as well as makes them cheaper. Additionally, access is influenced by
geographic, economic and socio-cultural factors as barriers to care. Poor distribution of
facilities, poor public transport, weak referral systems, insufficient community health
services and weak collaborations with other service providers have perpetuated poor
geographical access to health services (GoK,2013).
There are imbalances in geographical distribution of health facilities in terms of the
numbers and types of facilities available. Some areas have disproportionately more
19
facilities than others. Consequently, while the average distance covered to reach the
nearest health facility is reasonable (within 5 km for medical services, and 2.5km for
public health services as recommended by WHO), there are under-served areas in the
Country, particularly in the Northern Counties of Isiolo, Turkana, Mandera, West Pokot,
Marsabit, Samburu, Wajir, and Garissa.
Economic access constraints, affordability of health services also hinder access to services.
These include low house- hold income, low prioritization of health at household level and
low allocation of resources by the state to the health sector. Because of the high level of
poverty in Kenya, most households cannot afford to pay for health services. Where there is
some household income, health is not given priority. On its part, the government is
required to achieve the commitment in the Abuja Declaration to allocate 15% of
government expenditure budget to health. The measures include introduction of the
National Health Insurance Fund, review of the cost sharing strategy, promotion of
community pre-payment schemes and development of criteria for allocating public funds.
Socio-cultural barriers associated with low literacy levels, religious beliefs and gender bias
hinder access to health services, especially by women, children, adolescents, the disabled
and other vulnerable groups. Recognizing this problem, the government has to make the
provision of health services more humane, compassionate and dignified. Targeted
measures include ensuring privacy in the course of service delivery, especially for
women(WHO, 2015).
2.3.3 Kenya’s Improvement on Delivery of Primary Health Services in a
Devolved Health System
Several challenges in delivery of primary health care services still persist in Kenya. As
done by several other low and middle income countries, Kenya can get better value for
money by first focusing on making existing primary health facilities functional to deliver
quality health services. While the county fact sheets suggest that over a tenth of the
existing primary health care facilities are non-functional, the real situation appears to be
worse. Further, there is lack of data on functionality of over one thousand primary care
facilities built under the Constituency Development Fund.
The recent policy to offer free maternity services at all public health facilities is a step in
the right direction to improve access to skilled care at child birth, which is known to reduce
20
maternal deaths and thereby achievement of MDG4. However, the Service Readiness
Assessment Survey4 suggests wide variation in proportion of health facilities offering
basic emergency obstetric care across counties. Basic emergency obstetric care is much
easier to offer compared to comprehensive emergency obstetric care which requires
specialists, equipment, blood storage and an operation theatre.
The recent public expenditure tracking has shown that Kenyan health providers have much
better knowledge compared to several other countries in the region .Nearly 80% of health
staff could correctly diagnose five common health conditions and are aware how to
manage them. But, such knowledge is not optimally getting translated into service delivery
as only 40% of them were actually offering full treatment. Similarly about a third of health
staff are absent on a day of unannounced visit and over 80% of such absences were
authorized. However, there was no clear reason for nearly half of the staff on authorized
absence. Survey has shown that nearly two thirds of facilities had essential drugs and
supply was marginally better among facilities under pull system, generally facilities had
better availability of essential medicines for childcare compared to maternal care.
However, the pull system seemed to have helped to improve the supply of drugs for
maternal care.
A recent assessment of technical efficiency of health facilities suggests that generally
public primary health centers are more efficient in service delivery, but less than half of the
dispensaries need to improve their services.
2.4 Effect of Devolution on Health Care Work Force
The delivery of public health interventions requires skilled and adequately supported
health personnel. The term Human Resources for Health (HRH), according to the World
Health Organization (WHO), refers to all people engaged in actions whose primary intent
is to enhance health. These people include care givers (doctors, nurses, clinical officers,
pharmacists, etc.) to laboratory technicians, managerial personnel and other staff (cleaners,
medical records officers, health economists) who do not deliver any services to patients
directly but are vital to health system functioning. The importance of HRH is based on the
fact that delivering health services is what health workers do, supported by evidence of a
strong correlation between the density and quality of HRH in a country and population
health outcomes. HRH is one of the core building blocks of a health system and has two
21
essential components; Human Resources Development (HRD) and Human Resources
Management (HRM). These two components manage the life of a health worker from
training to employment and exit from the health workforce. How well these two
components are managed determines whether a country has numerically adequate and
motivated HRH.
Like most countries in Africa, the shortage of healthcare workers is not unique to Kenya.
Indeed, Kenya is one of the countries identified by the WHO as having a “critical
shortage” of healthcare workers. The WHO has set a minimum threshold of 23 doctors,
nurses and midwives per population of 10 000 as necessary for the delivery of essential
child and maternal health services. Kenya’s most recent ratio stands at 13 per 10 000.This
shortage is markedly worse in the rural areas where, as noted in a recent study by
Transparency International, under-staffing levels of between 50 and 80 percent were
documented at provincial and rural health facilities (KPMG,2013).
According to Scheffler, Bruckner &Spetz (2012) assessing the health labor market requires
to study both the demand and the supply sides, and how to match them in order to
determine shortages (or surpluses) of health workers. The supply of health workers
includes the number of qualified health workers willing to work at a given wage rate in the
health care sector (physicians, nurses and other care providers). Thus, training is a key
determinant of this part of the labour market. The number of trained health workers
depends on that of training institutions, the number of years of training, the education
level, the cost of training, the individual interest in working in that field, the expected
probability of getting a job after training, etc. It is linked to the market for training health
workers.
The demand for health workers, which is linked to the demand for health care, is measured
by the hiring of human resources for health by public and private institutions. Each of
these institutions competes, with varying wage rates, budgets, provider payment practices,
labour regulations and rules that determine hiring and wage decisions.
In general, the higher the wage, the larger the number of available health workers willing
to work for the health sector. Additional considerations, including better working
conditions, safety and career opportunities, also determine the decision to work in that
sector or rather to work in another sector or to migrate. The interaction between the supply
22
and demand for health workers determines the wages and other compensation, the number
of health workers employed, the number of hours they work, the geographical location and
their employment settings(Scheffler, Bruckner&Spetz, 2012).
2.4.1 Challenges in Human Resources for Health
The Kenya Health Policy 2012 – 2030, which is anchored on the Constitution, shows the
Government’s commitment to ensuring that citizens attain the highest possible standards of
health by supporting provision of equitable, affordable and quality health and related
services at the highest attainable standards to all Kenyans. The policy guides both County
and National Governments on the operational priorities they need to focus on in Health.
The country’s health sector still faces significant human resource shortages, in spite of the
investments the government has made over the years since independent and following the
devolution of health services (MoH, 2015). The situation is attributed to the increase in
population growth rate which has continued to put pressure on demand for health care
augmented by the freeze in recruitment of health personnel over time. The Ministry of
Health notes that human resource investments need to be designed to address the
availability of appropriate and equitably distributed health workers, attraction and retention
of required health workers, improving of institutional and health worker performance, and
finally training capacity building and development of the health workforce (MoH, 2015).
reports show that more than 5,000 Kenyan trained doctors have emigrated for reasons
attributable to poor pay and 3,000 more have left health to join others sectors, leaving
3,440 doctors for the nearly 46 million Kenyans who undoubtedly depend on national and
county hospitals (Kenya Health Labor Market Assessment Report of 2015). According to
Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPP&DU), the report did
not however capture the fact that majority of these doctors had either emigrated or left the
health sector after 2013, following the devolution of health services to the county
government. Many have cited negative effects of devolution including lack of schemes of
service at county level that continued to negatively impact on human resources’ practices
such as recruitment and retention, promotion, delayed salaries, lack of harmonization of
salaries, lack of opportunities for continuous medical education, among others. Measured
against the World Health Organization’s staffing norms and standards, Kenya has a
shortage of 83,000 doctors (Okech & Lelegwe, 2016).
23
2.4.2 Shifting Tasks to Lay Healthcare Workers in Primary Care
Task-shifting, already important in a continent with severe shortages of trained medical
personnel, is likely to be the only way to provide a quality, basic level of care to entire
populations. “We need to better leverage health workers,” DrDarkoh explains. “We don’t
necessarily need doctors and nurses to provide basic things like health education. We can
use so many other types of people with very little training and at little expense to build the
model of individual family and community ownership of health.”
Even non-professional people can be trained to provide education, support treatment for
HIV, deliver prescribed medicines, and use a weighing scale or glucose-testing device, say
DrDarkoh and others, freeing up specialized medical staff to perform more complicated
procedures and reducing the pressure on overstretched public-sector hospitals. One
example of such an initiative is Ethiopia’s health extension programme (HEP), which
trained extension workers to provide basic health information and education in rural areas
where none existed before.
“We recognize that communities themselves must own and lead the effort,” explains
TedrosAdhanom Ghebreyesus, minister of health for Ethiopia. Indeed, programmes such
as Ethiopia’s are particularly good at creating a cadre of health workers who do not have
advanced medical skills, but who, as local people already committed to their communities,
are also less likely to be poached by foreign healthcare systems. (The Economist
Intelligence Unit Limited [TEIUL], 2012) {The future of healthcare in Africa}
Other countries are looking at more regional solutions. In South Sudan, where human
resource shortages are at crisis levels, support from the Intergovernmental Authority for
Development (IGAD) allows neighboring countries to provide specialist labour to the
country. The originating countries continue to pay the workers’ salaries, and the South
Sudan government provides an allowance, according to DiaTimmermans, a senior health
adviser with the Joint Donor Office of the World Bank, based in South Sudan (TEIUL,
2012). Someof these challenges are currently being addressed through the proposed
staffing norms, private public initiatives such as “Beyond Zero” tolerance, managed
equipment scheme, construction of teaching referral hospitals in most of the counties.
Also, hard to reach counties are committed towards investing in human resources for
health while at the same time attract and retain them in services and have initiated various
24
incentives to attract and retain health workers such as performance best financing, risk
allowance, provision of air ticket and bonuses, among others. Planning and development of
human resources for health must be immediate action by the Ministry beyond the political
poetry of equipping county hospitals that doctors seem to have long deserted (Okech &
Lelegwe, 2016).
2.5 Chapter Summary
This chapter examined the impact of devolution on health infrastructure, access, health
care workforce, the theories and practical applications for health facilities. Several
examples were used to demonstrate the effects of devolution to health infrastructure,
workforce and access to primary health care. The next chapter will analyze the
methodology and design.
25
CHAPTER THREE
3.0 RESEARCH DESIGN AND METHODOLOGY
3.1 Introduction
This chapter outlines the overall research methodology that was used to carry out the
study. This includes the research design, population and sample size, data collection
methods, research procedures, data analysis and presentation.
3.2 Research Design
Research design provides the glue that holds the research project (Brown, Askew, Baker,
Denvir &Millet, 2003). A design is used to structure the research, to show how of the
major parts of the project-the sample or groups, measures, treatments or programs, and
methods of assignments-work together to try and address the central research questions.to
undertake the study, a descriptive research design will be used. This is a scientific study
done to a phenomenon or an object (Brown et al., 2003). This kind of study involves a
rigorous research planning and execution and includes answering research questions. This
method is preferred as it permits gathering of data from respondents in natural settings.in
this case, it’s possible for the researcher to administer the data collections tools to the
respondents in their work stations.
On the other hand, a case study focuses on a few branches selected from the total
population of other branches in the same industry (Cooper &Schindler,2000). a case study
involves intensive study of a relative small number of situations. The method was chosen
because it provides in-depth analysis of the research problem while providing valuable
insights for problem solving, evaluating and strategy.it therefore enables the researcher to
be more focused and provide analysis and recommendations that are specific and relevant.
A descriptive research design was employed in this study with an aim of securing a
representative sample of the relevant population to ensure the assessments of the target
population that would represent the general population. The research design was
appropriate for this study as it allowed for the analysis of the views of health care
personnel involved in health care. The sampling frame consisted of planning personnel
drawn from the Ministry of Medical Services and the Ministry of Public Health and
26
Sanitation. Multi-stage sampling technique was adopted in the study to identify the sample
elements. A self-administered structured questionnaire that contained both open-ended and
closed ended questions was used in collecting primary data. Additional data was collected
from theKenya health strategic plans, MTEFand Kenya Vision 2030. Others were relevant
journals, published authoritative sources from WHO and World Bank. Data collected was
cleaned, validated, coded for it to fit the statistical package. Finally, the analysis was
conducted using Statistical Package for Social Sciences (SPSS) and presented in form of
frequency tables, charts and graphs.
3.3 Population and Sampling Design
3.3.1 Population
Population defines the whole set of objects or events under investigation about which one
wishes to make inferences (Cooper & Schindler, 2003). Alarge set of observations is
referred to as a population while the smaller set is called the sample. In cases where the
population is very large a sample is often examined to make conclusions about the
population. The population of the study will be all 169 health hospitals in Nairobi County.
Stratified sampling will be used to select respondents based on cadres in order to have a
sample population that is representative. This will include Pharmacists, clinicians, Nurses,
medical officers, procurement officers and Hospital Managers.
3.3.2 Sampling Design and Sample Size
3.3.2.1 Sampling frame
A sampling frame is the list of the whole population under scrutiny from which a sample is
prepared (Cooper & Schindler, 2003).This is what is thought of as the list of all elements
in the population of interest. The sampling frame operationally targets the population from
which the sample is drawn and to which the sample data will be generalized. The sampling
frame for this study will be selected health facilities (dispensaries) and satellite clinics.
3.3.2.2 Sampling technique
To achieve a good representation of the sample and to increase reliability as well as
validity of the study as described by Saunder,Lewis& Thornhill (2012),the study used
stratified and cluster sampling to select health facility and respondents. This is where the
chance of each case being selected is not known. When the set of all possible items in a
population is very large it may be costly or time consuming to do a comprehensive analysis
27
of all the items. Therefore, evaluating characteristics of the entire population through a
representative sample will be more efficient while still proving the required information.
3.3.2.3 Sample size
A sample size is the section of part that represents the whole (Saunderset al., 2012). It is
the use of appropriate sampling techniques and with an adequate response rate is necessary
for a representative sample. Therefore, the sample size must be evaluated and all things
being equal, the greater the sampling size, the better to ensure there is more accuracy in the
results of the data taken. The sample size included a total 169 respondents selected
hospitals from selected county health facilities(Appendix 3).The strata used is as shown in
Table 2
Table 4: Nairobi County Health Facilities
Constituency Total Strata
Kamukunji 7 17
Starehe 9 18
Kasarani 13 22
Westlands 27 58
Embakasi 7 14
Njiru 4 8
Makadara 14 32
Total 81 169
3.4 Data Collection Methods
Data collection means gathering information to address those critical evaluation questions
that have been identified earlier in the evaluation process. The most important issue in data
collection is selecting the most appropriate information or evidence to answer the
questions formulated. The primary data collection method for this research was through
closed-ended questionnaire. The instrument allowed each person to respond to the same set
in a predetermined order. The questionnaire was developed by the researcher and
structured according to the research questions of the study. The instrument was physically
delivered to each health facility and respondents allowed reasonable time to complete.
Follow-ups were made through designated contact persons in the respective health
facilities. Both primary and secondary data were collected regarding health infrastructure
28
and personnel.
In terms of secondary data, a review of relevant literature on key policy initiatives and how
they have impacted on health infrastructure and personnel was undertaken. This
information was obtained from various sources including Ministry of Health official
documents such as the Kenya National Health Sector Strategic Plan (KHSSP) III, draft
Health Policy Framework, 2012 - 2030, draft Health Care Financing Strategy, and National
government documents such as Vision 2030, Medium Term Expenditure Framework
(MTEF) paperand the Constitution. Additional data was also collected from, journal
articles, among others. This was supported by in-depth interviews with key stakeholders in
the sector at county levels.
3.5 Research Procedures
A pilot test was conducted for 30 respondents in westlands sub-county health facilities to
verify the validity of the items in the closed-ended questionnaire. Based on the responses
of the pilot test, the questions were adjusted appropriately to increase clarity and ascertain
the time required to complete. The final questionnaire was reviewed and sent out to the
respondents. A letter of introduction, stating the purpose of the study was also attached to
each questionnaire.
3.6 Data Analysis Methods
The qualitative data was systematically organized using descriptive statistics to facilitate
analysis. Qualitative analysis is the examination of non –measurable data such as the
organizations reputation management, or a respondents’ feelings about a situation.
Descriptive statistics was used to analyze, explain and summarize properties of the data
collected aided by a Statistical Package for the Social Sciences (SPSS) and Excel. The data
was presented using graphs, charts and tables.
3.7 Chapter Summary
This chapter gave insight into how the study was conducted. Specifically, it has explained
the research design, study population, methods of data collection, research procedures, data
analysis and presentations. The primary data was collected with the aid of closed-ended
questionnaire that were administered by the researcher to the respondents in selected
branches and department. The data was analyzed by employing descriptive statistics such
as percentages and frequencies aided by SPSS and Excel. Presentation was through graphs,
29
charts and tables.Chapter four provides the results and findings followed by summary of
the findings, discussion, conclusion and recommendations in chapter five.
30
CHAPTER FOUR
4.0 RESULTS AND FINDINGS
4.1 Introduction
This chapter presented the results and findings of the primary data collected from the
respondents of Nairobi county healthcare facilities. It also presents the findings based on
research questions outlined in chapter one and results analyzed in form of graphs, charts
and tables. The research used a structured closed ended questionnaire.
4.2 Response Rate and General Information
4.2.1 Response rate
The sample of the study was 169 respondents from various health facilities in Nairobi
county One hundred questionnaires were issued and ninety-four questionnaires were
returned representing 94 per cent response rate. The other health facilities were not
covered due to inaccessibility and security reasons.
4.2.2 General information
The general information section gave an understanding of the profile of the respondents.
Questions on the department, position held, level of education, gender, age and the years of
service to the facility was presented.
4.2.2.1 Department
The study sought to find out the departments which respondents serve and the results are
analyzed in the Table 4.1
31
Table 4.1: Departments interviewed
Frequency Percent
Medical 42 45
Curative 8 8
Laboratory 13 14
Social Work 3 3
Procurement 9 10
Administration 17 18
Nutrition 2 2
Total 94 100
Table 4.1 above indicates that 45% of the respondents were in the medical department, 8%
curative, laboratory 14%, 3% social work,10% procurement,18% administration and 2%
nutrition.
4.2.2.2 Designation
The questionnaire sought to know the designation and the staffing of the respondents
across a range of cadres required for delivery of the Kenya Essential Package for Health
(KEPH) in the health system. The findings are summarized in Table 4.2.
Table 4.2: Position of respondents in the organization
Frequency Percent
Clinical Officer 25 27
Medical Officer 7 8
Pharmacist 5 5
Midwife 2 2
Laboratory Technician 13 14
Accountant 11 12
Nurse 7 7
Health Information Officer 5 5
Procurement Officer 10 11
Administrator 2 2
Consultancy 1 1
ICT expert 2 2
Driver 1 1
Nutrition officer 2 2
Social worker 1 1
32
Table 4.2 above indicates that 27% of the respondents were clinical officers, 14%
represented lab technicians, 12% accountants, 5% health information officers, 2% nutrition
officers, and other positons as shown above.
4.2.2.3 Level of Education
Level of education of the respondents was asked to know the literacy levels of the
respondents they are summarized in Table 4.3
Table 4.3: The level of education of the respondents
Frequency Percent
Diploma 33 35
Bachelor’s Degree 57 61
Master’s Degree 4 4
Table 4.3 above indicates that 35% of respondents had a diploma, 61% had a Bachelor’s
degree and 4% had a Master’s degree.
4.2.2.4 Gender
The study sought to know the gender balance in the health facility. The results were
presented in Table 4.4
Table 4.4: The gender of the respondents
Frequency Percent
Male 56 60
Female 38 40
Table 4.4 above indicates that 60% percent of the respondents were male and 40% were
female.
4.2.2.5 Age of the Respondents
The age bracket of the respondents was analyzed and this is shown in Table 4.5
33
Table 4.5: The age of the respondents
Frequency Percent
20-30 years 29 31
31-40 years 45 48
41-50 years 19 20
Over 51 years 1 1
Table 4.5 indicates that 31% respondents are aged between 20 to 30 years, 48% aged
between 31 to 40 years, 20% aged between 41 to 50 years and 1% over 51 years.
4.2.2.6 Years of Service in the Organization
Years of service to the institution was analyzed to know the retention rate of staff. The
findings are shown in Table 4.6
Table 4.6: The years of service in the organization
Frequency Percent
less than 2 years 35 37
3-5 years 41 44
6-8 years 17 18
over 9 years 1 1
Table 4.6 above indicates that 37% of the respondents have worked in the organization for
less than 2 years, 44% between 3 to 5 years, 18% between 6 to 8 years and 1 % above 9
years. This correlates with the findings in table 4.5 on age of respondents which shows the
employees are middle aged.
4.2.2.7 Difference between gender and position held
The study sought to find out if there was a difference between gender and position held in
the institution using independent t-test. The results are shown in the tables below:
34
Table 4.7: Difference between gender and position held
4.7 Group Statistics
your gender N Mean
Std.
Deviation
Std.
Error
Mean
your
position
Male 56 5.0000 4.00454 .53513
Female 38 5.3421 3.08682 .50075
Table 4.7above shows that there are 56 Males and 38 Females. The mean of the positions
for the gender of males was 5, and the mean of the positions for the gender of females was
5.3.
Table 4.8: Independent samples test
Levene's Test
for Equality of
Variances t-test for Equality of Means
F Sig. t df
Sig. (2-
tailed)
Mean
Difference
Std. Error
Difference
95% Confidence
Interval of the
Difference
Lower Upper
your
position
Equal
variances
assumed
3.522 .064 -.444 92 .658 -.34211 .76991 -1.87121 1.18700
Equal
variances
not
assumed
-.467 90.427 .642 -.34211 .73288 -1.79800 1.11379
Table 4.8 shows the levenes test of equality. If P< 0.05, reject Ho and accept H1 because
the variances/means are significantly different. If P>0.05, accept Ho, this means the
variances are not significantly different. Table 4.32.2 shows that P>0.05 which was
P=0.658 so we can say the mean variances between male and females and their position in
the institution is not significant.
4.3 The Effect of devolution on health infrastructure
In this section, the study sought to establish the effect of devolution on health
infrastructure in county health facilities. The study sought to know from respondents
whether hospital infrastructure had improved since county government came into place and
whether minimum basic facilities were available for proper running of the facility.
35
4.3.1 Cleanliness
Availability of clean toilets to staff and patients was analyzed to find out the level of
cleanliness and if they were in place. The findings are summarized in Table 4.9below:
Table 4.9: Clean toilets available for staff and patients
Frequency Percent
Yes 88 94
No 6 6
Table 4.9above shows that 94% of the respondents agree that clean toilets were available
to staff and patients and 6% disagreed.
4.3.2 Availability of protected placenta pit
The study sought to establish whether protected placenta pits were available within the
facility. The findings are summarized in Table 4.10
Table 4.10: Availability of protected placenta pit
Frequency Percent
Yes 46 49
No 48 51
Table 4.10above shows that 49% of the respondents agree to have a protected placenta pit
and 51% disagreed.
4.3.3 Disposal
The questionnaire sought to find out how the facility finally disposes of sharp waste, such
as needles or blades. The results are presented in Table 4.11
Table 4.11: Disposal of sharp wastes
Frequency Percent
Burn in incinerator 36 38
Open Burning 4 4
Remove offsite stored in covered container 54 58
Table 4.11above shows that 38% of the sharp wastes are burned in incinerators, 4% open
burning and 58% are removed offsite stored in covered containers.
4.3.4 Power supply
All health facilities should have some form of power supply. The study sought to find out
36
if the facility had a generator as a back-up or stand-by. The results are summarized in
Table 4.12
Table 4.12: Availability of a generator
Frequency Percent
Yes 89 95
No 5 5
Table 4.12 above shows that 95% of the respondents agree that the facilities have a
generator and 5% disagreed.
4.3.5 Water supply
Health facilities should have sufficient and clean piped water supply for drinking, personal
hygiene and, where applicable, for food preparation as per the health infrastructure norms
and standards. The study sought to find out if this was the case. Table 4.13 presents the
findings.
Table 4.13: Water supply
Frequency Percent
Piped into facility 82 87
Public tap 9 10
Borehole 2 2
Purchase from water
vendors 1 1
Table 4.13 above shows that 87% of the respondents have access to piped water to the
facility, 10% have access to public tap, 2% have a borehole and 1% purchase water from
water vendors.
4.3.6 Communication Facilities
Health facilities should have access to communication facilities for example phones, two
way radios among others. The results are shown in Table 4.14
Table 4.14: Communication Facilities
Frequency Percent
Yes 93 99
No 1 1
37
Table 4.14 above shows that 99% of the respondents had communication facilities and 1%
didn’t have.
4.3.7 Internet Facility
Health facilities should have a form of wired or wireless connectivity for purposes of
communication and information transfer, which should be maintained in good working
order. The study sought to find if health facilities had access to internet facility and the
findings are presented in Table 4.15
Table 4.15: Email /internet facility
Frequency Percent
Yes 76 81
No 18 19
Table 4.15 above shows that 81% of the respondents had access to email /internet within
the facility and 19% of the respondents didn’t have access.
4.3.8 Medical equipment
The research sought to find out the state of medical equipment in terms of its current
condition, functionality, its relevance, newer technology and if well maintained. The
findings are shown in Figure 4.1
38
Figure 4.5: State of medical equipment
Figure 4.1 above indicates that 5% of the respondents say the state of their medical
equipment is very good, 63% say it’s good, 6% say it’s very bad, 25% say it’s bad and 1%
didn’t know.
4.3.9 New equipment
The study sought to find out if new equipment has been bought since county government
came into place. The findings are summarized in Table 4.16
Table 4.16: New equipment
Frequency Percent
Yes 60 64
No 34 36
Table 4.16 above shows that 64% of the respondents said new equipment has been bought
since county government came into place and 36% disagreed.
4.3.10 Type of equipment bought
For those who said yes, the research wanted to know which equipment has been bought
since county government came into place. The findings are shown in Graph 4.1.
5%
63%
6%
25%
1%
State of medical equipment
Very good
Good
Very bad
Bad
Don’t know
39
Graph 4.1: New equipment bought since county government came into place
Graph 4.1 above shows that 15% of respondents said computers were bought, 7%
ambulances, 4% beds, 20% lab equipment, 12% X-ray machine, 3% generators, 2%
nebulizers and 37% didn’t know.
4.3.11 Transportation
The study sought to find out what mode of transport is used during emergencies by the
facility. The results are presented in Table 4.17
Table 4.17: Transport used during emergencies
0
5
10
15
20
25
30
35
40
15
7
37
4
20
12
32
Per
cen
t (%
)
New Equipment
New equipment bought
Frequency Percent
Ambulance 90 96
40
Table 4.17 above shows that 96% of respondents use ambulance during emergencies, 1%
use taxi, 1% use motorcycle and 2% use private cars.
4.3.12 Relation between budget for the year and state of medical equipment
The study sought to find out if there was a relationship between budget for the year and
state of medical equipment using correlation analysis. Table 4.18 presents the findings
Table 4.18: Correlation between budget for the year and state of medical equipment
Budget for
the year
State of
medical
equipment
Budget for the year Pearson
Correlation
1 .158
Sig. (2-tailed) .129
N 94 94
State of medical equipment Pearson
Correlation
.158 1
Sig. (2-tailed) .129
N 94 94
Table 4.18 above shows the Pearson’s r for the correlation is 0.158 which means that as the
budget for the year increases the state of medical equipment increase. We had a weak
positive correlation between size of the catchment population and the total number of staff.
The Sig. (2-Tailed) value in our case is 0.129. This value is more than 0.05. Because of
this, we can conclude that there is no statistically significant correlation between budget
for the year and the state of medical equipment.
4.4 The Effect of Devolution on Access to Health Services
In this sub-section results are presented in terms of how devolution has improved access to
health facilities. Like in the first case it sought to know from the respondents the proximity
of health facility to the community, availability of funds to run the facility, availability of
Taxi 1 1
Motorcycle 1 1
Private cars 2 2
41
transport and how well equipped the facility is adequate funding for medicines ,medical
supplies and adequate funding for maintenance of buildings.
4.4.1 Catchment population
This is the population that the health facility serves. The study sought to find out the
catchment population to which the county health facilities serve. The results are
summarized in Figure 4.2
Figure 4.6: Catchment population
Figure 4.2 above shows that 63% of the respondents’ facility, serve between 5000 to
10,000 people, 14% serve between 0 to 5,000 people and 23% serve over 10,000 people.
4.4.2 Transport used by patients
The study sought to find out what mode of transport is used by patients who are referred
from other facilities to the health facility during emergencies. The results are shown in
Table 4.19
Table 4.19: Transport used by patients referred from other facilities
Frequency Percent
Public bus 50 53
Private car 5 6
14%
63%
23%
Catchment population
0-5000 people
5000-10000 people
Over 10000 people
42
Ambulance 32 34
Motorcycle 3 3
People carry/push or pull
patient 2 2
Never receive referrals 1 1
Don’t know 1 1
Table 4.19 above shows that 53% of the respondents said that patients referred from other
facilities use public cars/bus,6% use private cars,34% use ambulance,3% use
motorcycle,2% people carry,1% never receive referrals and 1% don’t know.
4.4.3 Timeliness
The study sought to know how much time it takes for the patients to reach the healthcare
facilities. The results are summarized in Figure 4.3
Figure 4.7: How much time it takes patients to get to facility
Figure 4.3 above shows that 11% of the respondents said that patients take about 30
minutes to get to the facility,8% use 1 hour,3% use over 1 hour and 78% don’t know how
much time patients take.
4.4.4 Relationship between catchment area and time taken to get to facility
The study sought to find out if there was a relationship between catchment area and time
11%
8%
3%
78%
How much time it takes patients to get to facility
30 Mins
1 hour
Over 1 hour
Dont know
43
taken by patients to get to facility using correlation analysis. The findings are shown in
Table 4.20:
Table 4.20: Correlation between catchment area and time taken to get to facility
Correlations
size of the
catchment
population
How much
time it takes
patients to
get to
facility
size of the catchment population Pearson Correlation 1 .132
Sig. (2-tailed) .205
N 94 94
How much time it takes patients to get
to facility
Pearson Correlation .132 1
Sig. (2-tailed) .205
N 94 94
Table 4.20 shows the Pearson’s r for the correlation is 0.132 which means that there is a
weak relationship between catchment area and time it takes for patients to get to the
facility. This means that change in catchment area is not correlated with changes in the
time taken to get to facility. Also, Pearson’s r is positive which means that as the
catchment area increases in value, the time taken to get to facility also increase in value
and vice versa. Similarly, as one variable decreases in value, the second variable also
decreases in value.
The Sig. (2-Tailed) value in our case is 0.205. This value is greater than .05. Because of
this, we can conclude that there is no statistically significant correlation between catchment
area and time taken by patients to get to facility.
4.4.5 Funding
What is the source of funding for the facility. The results are presented in Figure 4.4
44
Figure 4.4: Source of funding
Figure 4.4 above shows that 6% of respondents are funded by donors, 53%
bymainstream government and 41% by local government.
4.4.6 Budget for the year
The study sought to find out what the budget for the year was. The findings are
presented in Figure 4.5
41%
53%
6%
Source of funding
Government
Local Government
Donors
45
Figure 4.5: Budget for the year
Figure 4.5 above indicates that 59% of the respondents’ budget for the year was between
1,000,001 to 7, 000, 000, 40% between 500,001 to 1,000,000 and 1% between 250,000 to
500,000.
4.4.7 Relation between source of funds and budget
The study sought to find out if there was a relationship between source of funding and the
budget the facility received for the year using correlation analysis. Table 4.21 presents the
findings
Table 4.21: Correlation between source of funds and budget
Source of
funding
Budget for the
year
Source of funding Pearson Correlation 1 -.265**
Sig. (2-tailed) .010
N 94 94
Budget for the year Pearson Correlation -.265** 1
Sig. (2-tailed) .010
N 94 94
**. Correlation is significant at the 0.01 level (2-tailed).
Table 4.21 above shows the Pearson’s r for the correlation is -0.265 which means that as
source of funding increases in value, the budget for the year decreases in value. We had a
weak negative correlation between source of funding and the budget.
1%
40%
59%
Budget for the year
250,000-500,000
500,001-1,000,000
1,000,001-7,000,000
46
The Sig. (2-Tailed) value in our case is 0.001. This value is less than 0.05. Because of this,
we can conclude that there is a statistically significant correlation between source of
funding and budget for the year.
4.4.8 Adequate Funding
The study sought to know if adequate funding is allocated for purchase of medicines,
equipment and maintaining buildings. The results are presented in Table 4.22
Table 4.22: Adequate funding allocated for medicine
Frequency Percent
Yes 16 17
No 78 83
Table 4.22above shows that 17% of the respondents agree that there is adequate funding
for medicine and 83% disagreed.
Table 4.22: Adequate funding allocated for equipment
Frequency Percent
Yes 21 22
No 73 78
Table 4.22 above shows that 22% of the respondents agree that there is adequate funding
for equipment for the facility and 78% disagreed.
Table 4.23: Adequate funding allocated for maintaining buildings
Frequency Percent
Yes 12 13
No 82 87
Table 4.23 above shows that 13% of the respondents agree that there is adequate funding
for maintaining buildings and 87% disagreed.
4.4.9 Unit for repair and maintenance
The research sought to know if there was a designated unit for repair and maintenance of
equipment which have to be in good working condition for effective running of the
hospital. The results are shown in Table 4.24
47
Table 4.24: Designated unit for repair and maintenance of equipment
Table 4.24 above shows that 36% of the respondents had a designated unit for repair and
maintenance of equipment and 64% didn’t have.
4.4.10 Unit for repair and maintenance predicts the state of medical equipment
The study sought to find out if availability of a unit for repair and maintenance predicts the
state of medical equipment using simple linear regression model. The results are shown in
Tables 4.25.1, Table 4.25.2, Table 4.25.3
Table 4.25: Unit for repair and maintenance predicts the state of medical equipment
4.25.1 Model Summary
Model R R Square Adjusted R Square
Std. Error of
the Estimate
1 .327a .107 .097 .91046
a. Predictors: (Constant), Do you have a designated unit for repair and
maintenance of equipment
Table 4.25.1 shows the R value is 0.327 which is the simple correlation and indicates a
weak degree of correlation. The R2 value is 10.7% which indicates how much of the total
variation in the dependent variable, state of medical equipment, can be explained by the
independent variable, availability of a repair and maintenance unit. In this case, 10.7% is
very low.
4.25.2 ANOVAa
Model
Sum of
Squares df
Mean
Square F Sig.
1 Regression 9.142 1 9.142 11.028 .001b
Residual 76.263 92 .829
Total 85.404 93
a. Dependent Variable: State of medical equipment
b. Predictors: (Constant), Do you have a designated unit for repair and
maintenance of equipment
Table 4.25.2 shows p< 0.001 which is less than 0.05, and indicates that, overall, the
regression model statistically significantly predicts the outcome variable (i.e., it is a good
Frequency Percent
Yes 34 36
No 60 64
48
fit for the data).
4.25.3 Coefficientsa
Model
Unstandardized
Coefficients
Standardized
Coefficients
t Sig. B
Std.
Error Beta
1 (Constant) 1.469 .334 4.401 .000
Do you have a
designated unit
for repair and
maintenance of
equipment
.649 .195 .327 3.321 .001
a. Dependent Variable: State of medical equipment
From table 4.25.3 we can state the regression equation as:
Unit for repair and maintenance=1.469+0.649 (state of medical equipment)
4.4.11 Basic emergency obstetric care
The research sought to know if the health facility offered basic emergency obstetric care
that is care during pregnancy, child birth and the postpartum period. The results are
presented in Table 4.26
Table 4.26:Offer basic emergency obstetric care
Frequency Percent
Yes 87 93
No 7 7
Table 4.26 above indicate that 93% of the respondents agree to offering basic emergency
obstetric care and 7% disagreed.
4.4.12 Emergency obstetric care that require specialists
The study sought to find out what happens to comprehensive emergency obstetric care that
require specialists as county health facilities don’t have specialists. The results are shown
in Table 4.27
Table 4.27: Emergency obstetric care that require specialists
Frequency Percent
Don’t
know 24 26
49
Referrals 70 74
Table 4.27 above indicates that 74% of the respondents said during comprehensive
emergency obstetric care that require specialists’ patients are referred to higher level
facilities and 26% didn’t know what happens to such cases.
4.4.13 Free maternity services
The study sought to find out if the county health facilities offered free maternity services.
The findings are presented in Table 4.28
Table 4.28: Free maternity services
Frequency Percent
Yes 87 93
No 7 7
Table 4.28 above indicates that 93% of the respondents offered free maternity services and
7% disagreed.
4.4.14 Labour ward
All primary health care facilities are required to have a labour ward. The study sought to
find out if this was the case. The results are summarized in Table 4.29.
Table 4.29:Labour ward
Frequency Percent
Yes 65 69
No 29 31
Table 4.29 above indicates that 69% of the respondents had a labour ward and 31% did not
have.
4.4.15 Inpatient care
The study sought to find out if the facility provided inpatient care. Table 4.30 presents the
findings
Table 4.30: Offer routinely inpatient care
Frequency Percent
Yes 32 34
50
No 62 66
Table 4.30 above indicates that 34% of the respondents routinely offered inpatient care and
66% disagreed.
4.4.16 Beds
The study sought to find if the facility had beds for overnight observations. Table 4.31
presents the findings:
Table 4.31: Have beds for overnight observation
Frequency Percent
Yes 39 42
No 55 58
Table 4.31above indicates that 42% of the respondents had beds for overnight observation
and 5% disagreed.
4.4.17 Number of inpatient beds
The study sought to find out how many inpatient beds the facility had. The results are
shown in Graph 4.2
51
Graph 4.2: Number of inpatient beds
Graph 4.2 above indicates that 68% of the respondents didn’t have inpatient beds, 6% had
two beds, 4% had 10 beds, 5% had 20 beds, 2% had 50beds and 1% had 4 beds.
4.4.18 Condition of laboratory
The study wanted to find out the condition of the laboratory. The findings are shown in
Figure 4.6
0
10
20
30
40
50
60
7068
61 1 2 1
41 1 3 5
1 2 2
Per
cen
t
Number of beds
How many inpatient beds
52
Figure 4.6: Condition of laboratory
Figure 4.6 above shows that 7% of respondents said that their laboratory is in very good
condition, 78% say it’s good, 1% say it’s very bad and 14% say it is bad.
4.4.19 Replenishment of medical supplies
The study sought to find out how often medical supplies was replenished. The findings are
shown in Figure 4.7
Figure 4.7: Replenishment of medical supplies
Figure 4.7 above shows that 5% of the respondents had monthly replenishment of medical
supplies, 34% quarterly, 52% half yearly and 9% yearly.
7%
78%
1% 14%
Condition of Laboratory
Very
good
Good
5%
34%
52%
9%
Replenishment of medical supplies
Monthly
Quarterly
Half yearly
Yearly
53
4.4.20 Frequency of store audit
The study sought to find out how frequent the health facility store was audited. The results
are presented in Figure 4.8
Figure 4.8: Store audit
Figure 4.8 above shows that 9% of the respondents had their stores audited monthly, 22%
quarterly, 65% half yearly and 4% yearly.
4.5 The Effect of Devolution on Health Care Workforce
This section tried to analyze how devolution has improved healthcare workforce. Like in
the previous two cases it sought to know from the respondents the number of staff, if they
receive any medical education, mechanisms used to motivate them, if they receive any job
promotion and things related to the work environment they would want improved.
4.5.1 Number of staff
The study sought to find out the total number of staff the facility had. The findings are
shown in Table 4.32
Table 4.32: Number of staff
Frequency Percent
9%
22%
65%
4%
How often is store audited
Monthly
Quarterly
Half Yearly
Yearly
54
1-5 staff 3 3
5-10staff 11 12
10-15staff 72 77
More than
15 8 8
Table 4.32 above indicate that 3% of the respondents had between 1 to 5 staff ,12%
between 5 to 10 staff ,77% between 10 to 15 staff and 8% more than 15 staff.
4.5.2 Adequately staffed
We sought to find out if in the respondents’ opinion they were adequately staffed. The
findings are shown in Table 4.33
Table 4.33: Adequately staffed
Frequency Percent
Yes 5 5
No 89 95
Table 4.33 above indicates that 5% of the respondents said they were adequately staffed
and 95% disagreed.
4.5.3 Medical education
The research sought to know if the facility offered continual medical education to their
staff, and if they did, the type of education as shown in Table 4.34 and Graph 4.3
Table 4.34: Continual medical education
Frequency Percent
Yes 47 50
No 47 50
Table 4.34 above indicates that 50% of the respondents agreed that they receive continual
medical education and 50% disagreed.
55
Graph 4.3: Medical education received
Graph 4.3 above shows that 50% of the respondents didn’t receive any continual medical
education, 10% received training on first aid, 7% on first aid, 3% on obstetric emergencies
and 2 % on diarrhea among others.
4.5.4 Appraisal
The study sought to find out if the facility did any appraisal as a performance monitoring
tool. Table 4.35 presents its findings:
Table 4.35: Existence of appraisal
Frequency Percent
Yes 88 94
No 6 6
Table 4.35 indicates that 94% of the respondents did appraisals and 6% did not do
appraisals.
4.5.5 Frequency of appraisals
The research sought to find out the frequency of appraisals done. The findings are shown
in Figure 4.9:
05
101520253035404550
50
1310 7 9
4 3 2 2
Per
cen
t
Type of education
Type of medical education received
56
Figure 4.9: Frequency of Appraisals
Figure 4.9 above shows 20% of respondents do quarterly appraisals, 55% half yearly, 19%
yearly and 6% don’t do appraisals.
4.5.6 Motivation
The study sought to find out if there were any mechanisms used to motivate staff. Table
4.36 presents the findings:
Table 4.36: Mechanisms used for staff motivation
Frequency Percent
Tea for staff 11 12
Lunch for staff 6 7
Awards 13 14
Letters of appreciation 6 6
Time-off 3 3
No mechanisms for staff
motivation 54 57
Trainings 1 1
Table 4.36 above indicates that 12% of the respondents were offered tea as a motivator,
7% lunch,14% awards,6% letter of appreciation,3% got time-off,57% no mechanisms used
and 1% through training.
20%
55%
19%
6%
How often are appraisals done
Quarterly
Half yearly
Yearly
Others
57
4.5.7 Promotion
The research wanted to find out if employees received promotions for good performance or
any form of formal recognition. Table 4.37 presents the findings:
Table 4.37: Receive promotion
Frequency Percent
Yes 89 95
No 5 5
Table 4.37 above indicates that 95% of the respondents received promotion for an
employee’s good performance and 5% disagreed.
4.5.8 Criteria for promotion
The study sought to find out the criteria used when promoting staff. Table 4.38 presents the
findings:
Table 4.38: Criteria for promotion
Frequency Percent
Appraisals 42 45
Academic qualifications 51 54
Others 1 1
Table 4.38 above indicates that 45% of the respondents received promotion based on
appraisals done,54% academic qualifications and 1% others not specified.
4.5.9 Things to be improved
The study sought to find out if there are things related to the working situation that the staff
would like to see improved and would enhance their ability to provide good quality of care
services. The results are summarized in Graph 4.4
58
Graph 4.4: Areas of Improvement
Graph 4.4 above shows that 54% of the respondents would love to be trained to improve
their ability to provide quality care services,7% more knowledge,3% more support from
supervisors,16% more supplies,5% better quality equipment,5% emotional support to staff
among others.
4.5.10 Relation between catchment area and number of staff
The study sought to find out if there was a relationship between catchment area and the
number of staff using correlation analysis. Table 4.39 presents the findings
Table 4.39: Correlation between size of the catchment population and total number of
staff
Total number of staff
size of the
catchment
population
0
10
20
30
40
50
60 54
73
16
5 6 4 5
Per
cen
t
Thing to be improved
Things that need to be improved
59
Total number
of staff
Pearson
Correlation
1 .276**
Sig. (2-
tailed)
.007
N 94 94
size of the
catchment
population
Pearson
Correlation
.276** 1
Sig. (2-
tailed)
.007
N 94 94
**. Correlation is significant at the 0.01 level (2-tailed).
Table 4.39 above shows the Pearson’s r for the correlation is 0.276 which means that as the
size of the catchment population increases the total number of staff increase in value. We
had a weak positive correlation between size of the catchment population and the total
number of staff.
The Sig. (2-Tailed) value in our case is 0.007. This value is less than 0.05. Because of this,
we can conclude that there is a statistically significant correlation between size of the
catchment population and the total number of staff.
4.1 Chapter summary
The chapter highlighted the findings of the study which was to assess the impact of
devolution on health care systems using the case of Nairobi county health facilities. The
results were based on research questions from where a questionnaire was prepared and
administered to respondents. The data collected was analyzed and findings presented in
descriptive statistics in form of pie charts, graphs and tables. Chapter five presents the
discussions, conclusions and recommendations.
60
CHAPTER FIVE
5.0 SUMMARY, DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS
5.1 Introduction
This section presents a summary and discussions of the major findings. The chapter also
draws conclusions, makes recommendations for improvement, and finally provides areas
where further studies can be conducted.
5.2 Summary of findings
The purpose of this study was to assess the impact of devolution on healthcare systems
with a focus on Nairobi county health facilities. The study was guided by three research
questions namely; what is the effect of devolution on health infrastructure? what is the
effect of devolution on access to health services? what is the effect of devolution on health
care workforce? The research targeted a population of ninety-four employees working in
various departments in county health facilities and used a stratified sampling technique.
Primary and secondary sources of data were used in this study where primary sources of
data were collected by use of closed ended questionnaire after a pilot test had been
conducted. The collected data was analyzed using SPSS to compute both descriptive and
inferential statistics including frequencies, charts, t-tests, regression and correlation. The
results were thereafter presented in form of tables, graphs and charts.
The study revealed that majority of the respondents agreed that hospital infrastructure had
improved with devolution. Most facilities had piped water to the facilities, availability of
communication facilities, had power/electricity and backup generators. It was also
observed that medical equipment was in good condition in most facilities in terms of its
functionality and new equipment had been acquired under the medical equipment scheme
such as x-ray machines, nebulizers, lab equipment among others.
The findings on access to healthcare services revealed that majority of respondents agreed
that adequate funding is not allocated for purchase of medicines, purchase of equipment
and maintenance of buildings and ambulances was the most common means of transport
used by health facilities during emergencies. The findings on healthcare workforce
revealed that majority of the respondents agreed that they were inadequately staffed. Also
most of the respondents agreed that more training would mostly improve their ability to
61
provide quality care services. Of importance to note, was the lack of motivation
mechanisms by majority of the healthcare facilities that led to low morale of staff thus
under productivity.
5.3 Discussion
The findings from the study are discussed here according to research questions. It entails
interpretations of the results or major findings by comparing them with the theoretical
background presented in the literature review.
5.3.1 The Effect of Devolution on Hospital Infrastructure
The findings revealed that most of the respondents agreed to a great extent that they have
communication facilities. Also, a large proportion of the respondents suggested that to a
great extent internet facilities are available. Health infrastructure relates to all the physical
infrastructure, non-medical equipment, transport, and technology infrastructure (including
ICT) required for effective delivery of services (KHP, 2014).
The findings revealed that most of the respondents agreed to a great extent that the state of
their medical equipment was good and most of the respondents agreed to new equipment
being bought. Some of Kenya’s health facilities lack adequate premises for priority
interventions, such as delivery rooms, maternity, laboratories, theatres (GoK, 2005). The
findings revealed that most of the respondents agreed to a great extent that they had labour
wards and good state of laboratories. Physical infrastructure is one of the most important
facilities to a health facility for it to provide quality care. Most of medical equipment used
in public health facilities is more than 20 years old (some double their lifespan) and
characterized by frequent breakdowns. Furthermore, most public facilities do not have
modern equipment such as dialysis machines, radiology equipment, laundry machines and
theatre equipment. The available equipment falls far short of the required numbers, of
those available, about 50% of the equipment is too old to pass required standards and that
maintenance of equipment has been inadequate (MoH, 2015).
The findings also revealed that most of the respondents agreed to have piped water to the
facility Similarly, MoH (2017) points out that all health facilities should have sufficient
and clean piped water supply which complies with all relevant laws and which is available
at all times for drinking, personal hygiene and, where applicable, for food preparation.
Sufficient water collection points and water use facilities must be available at all Health
62
facilities to allow convenient access.
On the other hand, most of the respondents didn’t have protected placenta pits. This
contradicts (MoH,2017) that states all primary health facilities should have at least one
protected placenta pit. Similarly MoH (2016) observed that most dispensaries lack placenta
pits and septic tanks for the safe disposal of maternity health care wastes. Keeping the
health infrastructure and the equipment in good condition would undoubtedly change the
public’s perception of good quality care and this in turn would encourage people to use the
available health services (GoK, 2005). Health infrastructure is key in restoring public
perception of good quality care and achieving devolution goals on improvement of primary
health care facilities.
5.3.2 Effects of Devolution on Access to Health Services
Access implies physical distance, financial outlays and socio-cultural factors. Improving
access – geographically, financially and socioculturally – is expected to increase the
utilization of health care services, as the services become closer and cheaper for the client
(GoK, 2005). The findings revealed that most of the respondents had inadequate funding
for medicines, equipment and maintenance of buildings. The observations made by the
(MOH: NHA 2009/10) stated that the small share of the health sector in the Government
budget (in 2009/10 only 4.6%) points to a general underfinancing of publicly provided
services which is in agreement with the findings.
The findings have shown change with devolution where most respondents agreed that there
was availability of ambulances during emergencies and comprehensive cases that require
specialists had referrals done.KHSSP (2017) stated that, poor public transport, weak
referral systems, insufficient community health services and weak collaborations with
other service providers have perpetuated poor geographical access to health services. The
findings revealed that most of the respondents agreed to have offered free maternity
services to their patients. As observed by the Service Readiness Assessment Survey4,the
recent policy to offer free maternity services at all public health facilities is a step in the
right direction to improve access to skilled care at child birth, which is known to reduce
maternal deaths and thereby achievement of MDG4.
The findings revealed that most respondents served an average population of between 5000
to 10,000 people, which shows a low reach out to the intended population. This is contrary
63
to KEPH (2013) that states that a health centre should serve an average population of
30,000 people. GoK (2005) states that, access is a measure of the ability of a
person/community to receive available services. It is a pre- requisite to high utilization of
health services as it brings services closer to the people as well as makes them cheaper.
5.3.3 Effects of Devolution on Health Care Workforce
The findings revealed that most of the respondents suggested that to a great extent they are
inadequately staffed. This is in agreement with the MOH observation that states, the
country’s health sector still faces significant human resource shortages, in spite of the
investments the government has made over the years since independent and following the
devolution of health services (MoH, 2015).
Shortage of healthcare workers affects functionality of health institutions. The findings
revealed that most of the respondents had between 10-15 staff. As stated by the WHO that
set a minimum threshold of 23 doctors, nurses and midwives per population of 10 000 as
necessary for the delivery of essential child and maternal health services (KPMG, 2013).
The findings also revealed that most of the respondents agreed that training would be one
of the things they would love to see, that would improve their staff ability to provide good
quality care of services. MoH,(2015) notes that human resource investments need to be
designed to address the availability of appropriate and equitably distributed health workers,
attraction and retention of required health workers, improving of institutional and health
worker performance, and finally training capacity building and development of the health
workforce.
The findings also revealed that majority of the respondents had no mechanisms put in
place for staff motivation. As stated by the Kenya HRH Strategic Plan and from the
Ministry of Health’s signed commitments at the Human Resources for Health Conference
in Brazil in 2013, under commitment 4, there needs to be increased spending in the Health
Sector on HRH beyond staff salary and allowances by 2017. Allocate HRH budgets
beyond employee’s emoluments towards employee welfare, employee relations, reward
and recognition, work climate improvement, occupation health and safety by 2017.
5.4 Conclusion
The following conclusions were drawn from the research findings based on the research
64
question which was to analyze the impact of devolution on health care systems using the of
Nairobi county health facilities.
5.4.1 The Effect of Devolution on Health Infrastructure
Availability of good health facility infrastructure would undoubtedly change the public’s
perception of good quality care. Communication facilities was one of the most improved
hospital infrastructure. The state of medical equipment was good and new equipment had
been bought with devolution of health services. Also to note was the availability of labor
wards, laboratories were in good condition, although placenta pits were the least available
in the health facilities. This means that there was considerable improvement on health
infrastructure with devolution.
5.4.2 The Effect of Devolution on Access to Health Services
Access to health services significantly affect utilization of health care services. With
devolution, ambulances were available for emergency services, free maternity was
available which implies skilled care available at child birth thus a reduction on maternal
deaths. Inadequate funding was allocated to medicine, equipment and maintenance of
buildings which implies underfunding and, the catchment area that the county health
facilities served was low and needs to be improved.
5.4.3 The Effects of devolution on health care workforce
Health workers are a backbone to health facilities. A shortage of health workers in the
facilities implies that strain is put on the available staff that in turn affects their service
delivery. Devolution has not addressed this challenge yet. No mechanisms were put in
place to motivate staff ,only a few health facilities, implying that Nairobi county healthcare
workforce is majorly demotivated, finally most staff wanted more training to be done that
would improve their service delivery.
5.5 Recommendations
In this sub-section recommendations are provided. These are provided in terms of
recommendations for improvements and recommendations for further studies.
65
5.5.1 Recommendations for improvement
5.5.1.1 The effect of devolution on hospital infrastructure
The study recommends that county health facilities need to improve their infrastructure in
terms of having well maintained equipment, purchase of specialized equipment so as to
restore public perception of good quality care and achieve devolution goals on
improvement of primary health care facilities. The equipment should be in good working
condition and counties should consider having designated units for repair and maintenance.
Public health technicians who were trained to maintain physical infrastructure should be
hired and the minimum infrastructural standards should be met by the county health
facilities.
5.5.1.2 The effect of devolution on access to health services
The study recommends that that county health facilities should increase their catchment
area to be able to serve a wider population also the health facilities should be distributed
equally in a manner that a facility is not overwhelmed while the other serves a few clients.
More funding needs to be allocated to purchase of medicines, equipment and maintenance
of buildings. This can be done by improving county health facility budgets through
expanding their source of income and not entirely depending on main government and
county government.
5.5.1.3 The effect of devolution on healthcare workforce
The study recommends hiring of more workers to address the shortage of healthcare
workforce in healthcare facilities. This can also be done by emulating best practices where
non-professional people can be trained to provide basic health care management in terms
of education, support treatment for HIV, deliver prescribed medicines and others, freeing
up specialized medical staff to perform more complicated procedures. Also, because of
low morale by health workers’ county health facilities should have various incentives to
attract and retain them, such as giving risk allowance, provision of bonuses, among others.
5.5.2 Recommendations for Further Studies
More case studies should be done on the other counties to ascertain whether there has been
improvement on county health facilities with the advent of devolution. It is also critical
that future researchers investigate the impact of county funding on devolution of health
66
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APPENDICES
Appendix 1: Introduction Letter
70
November, 2016
Dear Respondent,
REF: REQUEST FOR RESEARCH DATA
I am a Master of Business Administration (MBA) student at the United States International
University, Nairobi. I am required to submit as part of my course work assessment a
research project report on ‘the impact of devolution on healthcare systems’. The study
uses county Healthcare facilities in Nairobi and you have been selected as one of the
respondents. I kindly request you to fill the attached questionnaire to generate the data
required for this study. This information will be used purely for academic purpose and
your name will not appear anywhere in the report. Findings of the study shall upon request
be availed to you.
Your assistance and cooperation will be highly appreciated.
Thank you in advance.
Truphena M. Gimoi (Researcher)
Contact : 0723 593571
Appendix 2: Questionnaire
This questionnaire has been designed to collect information from selected staff of county
Health facilities and is meant for academic purposes only. The questionnaire is divided
into three sections. Please complete each section as instructed. Do not write your name or
71
any other form of identification on the questionnaire. All the information collected from
the questionnaire will be treated with strict confidentiality.
Part A: General Information
Kindly answer all the questions either by ticking in the boxes or writing in the spaces
provided.
1. Department or branch:-------------------------------------------------------------
2. Position in the organization: Clinical OfficerMedical officerPharmacistMidwife
Laboratory technician AccountantNurse Health Information officer
Procurement officerother (specify) …………………………………………………..
3. Level of education: Diploma Bachelor’s degree Master’s degree
4. Your gender: Male Female
5. Your age: 20-30 years 31-40 years 41-50 years Over 51 years
6. The years you have worked in the organization: Less than 2 years 3-5 years 6-8
years Over 9 years
Part B: Hospital Infrastructure
7. Are clean toilets or latrines available for staff and patients/clients?
Yes No
8. Do you have a protected placenta pit?
Yes No
9. How does this facility finally dispose of sharps waste, such as needles or blades or what is
the final disposal process for filled sharps boxes in this facility?
Burn in incinerator Open burning Dump without burning
Remove offsite stored in covered containerNever have sharps waste
Other (specify) ……………………………………………………………
10. Does this facility have a generator for electricity? This may be a back-up or stand-by
generator.
Yes No
11. What is the most commonly used source of water for the facility?
72
Piped into facility Public tap Borehole Protected spring Unprotected
springRainwater others specify
12. Do you have communication facilities(e.g. phones, two way radio)
Yes No
13. Is there ever access to email/internet within the facility?
YesNo
PART C: ACCESS
14. Do you have an estimate of the size of the catchment population that this facility serves, i.e.,
the target or total population living in the area served by this facility? How many people is
that?
0-5,000people 5000-10,000people over 10,000people
15. What transport do you use during emergencies?
Ambulance Taxi Motorcycle others specify
16. What is the most common means of transport used by patients who are referred from other
facilities to this facility for emergency services?
Public car/bus Private car AmbulanceMotorcycleBicyclePeople carry/push or
pull patient. Never receive referrals don’t knowother (specify)
17. How much time does it take to for the patients to reach the health care facilities?
30 mins
1hour
Over 1hr
Don’t know
If more than 1hour what could be causing the delay?
…………………………………………………………………………………….
18. What is your source of funding?
73
Government Local Government Donors Pre-payment schemes NHIF
others specify
19. What was your budget for the year?
250,000-500,000500,000-1,000,0001,000,000-7,000,000Others specify
20. Is adequate funding allocated for:
Medicine Yes No
Equipment Yes No
Maintaining buildings Yes No
21. What is the state of medical equipment?
Very GoodGood Very bad Bad None
22. Has new equipment been bought since county government came into place?
Yes No
If yes please specify……………………………………………………….
23. Do you have a designated unit for repair and maintenance of equipment?
Yes No
If No, where are the equipment repaired?..........................................................
24. Does your health facility offer basic emergency obstetric care?(i.e. pregnancy, child birth
and the postpartum period)
Yes No
74
25. What happens to comprehensive emergency obstetric care which requires specialists?
Explain
………………………………………………………………………………………………
………………………………………………………………………………………………
26. Do you offer free maternity services?
Yes No
27. Do you have a labour ward
Yes No
28. Does this facility routinely provide inpatient care?
Yes No
29. Does this facility have beds for overnight observation?
Yes No
30. How many overnight or inpatient beds does this facility have?
Number of beds
31. What is the condition of your laboratory?
Very GoodGood Very bad Bad others specify
32. How often do you replenish your medical supplies?
Monthly Quarterly Half yearly Yearly others specify
33. How often is the store audited?
Monthly Quarterly Half yearly Yearly others specify
PART C: HEALTHCARE WORKFORCE
34. What is the total number of staff?
75
1-5 staff 5-10staff 10-15 staffothers specify
35. In your opinion would you say you are adequately staffed
Yes No
36. Do you receive continual medical educational activities?
Yes No
If Yes, which ones?
................................................................................................................................................
............................................................................................................................................
37. Do you do appraisal?
Yes No
After how long
Quarterly Half yearly Yearly others specify
38. What mechanisms are used for staff motivation?
Tea for staff Lunch for staff Awards Letters of appreciationTime-offother
forms please state No mechanisms for motivation
39. Do you receive promotion for an employee good performance or any form of formal
recognition?
Yes No
40. What is the criteria for promotion?
AppraisalsAcademic qualifications others Specify……………....................
76
41. Are there things related to your working situation that you would like to see improved,
can you tell me the three things that you think would most improve your ability to provide
good quality of care services?
Training more knowledge / updates more support from supervisor
More supplies/stock Better quality equipment Better facility infrastructure
More autonomy/ independence Emotional support for staff (counseling / social
activities) others(specify)
Circle only three items.
****Thank you for taking your time to complete this questionnaire****
Appendix 3: Sample size
1. KAMUKUNJI
1 EastLeigh H/C Location: EastLeigh Section 7 2
77
2 Biafra clinic Location: Biafra estate 2
3 PumwaniMajengo H/C Location: Gikomba Open air market 5
4 ShauriMoyo Location: ShauriMoyo estate shopping centre 2
5 Muthurwa Location: Muthurwa market/bus terminus 2
6 Bahati H/C Location: Bahati Estate 2
7 Jerusalem Clinic Location: Jerusalem estate 2
2. STAREHE
1. Ngaira H/C Location: Off Hailesellasie Avenue, next to government
press
2
2. Rhodes Chest clinic Location: Ngaira health centre, next to
government press
2
3. Ngara H/C Location: Park Road 2
4. Kariokor Clinic Location: Opposite Ziwani shopping centre 2
5. Pangani Clinic Location: Pangani estate 2
6. STC Casino H/C Location: Off River Road 2
7. Huruma Lions H/C Location: Huruma Estate, next to Huruma grounds 2
8. Lagos Rd. Disp. Location: Lagos Road, next Marble Arch Hotel 2
9. Mathare Police Depot Location: Mathare Police Post shooting range 2
3. KASARANI
1. Mathare North H/C Location: Mathare North estate 2
2. Kariobangi North H/C Location: Old Kariobangi estate 2
78
3. Kasarani H/C Location: Kasarani DC’s office 2
4. Kahawa West H/C Location: Kahawa West estate 2
5. Babadogo H/C Location: Babadogo road, Ruaraka 2
6. NYS H/C Location: National Youth Service H/Q, Ruaraka 2
7. GSU Hq H/C Location: GSU hqRuaraka 2
8. Kamiti Prison H/C Location: Kamiti 2
9. Ruiru PSTC Location: Ruiru prison 2
10. CID Hq’sDisp.Location: Nairobi Area Police Hq 2
11. GSU RuiruDisp.Location: Ruiru GSU camp 2
4. WESTLANDS
1. Westlands H/C Location: Westlands 3
2. Kangemi H/C Location: Waiyaki way, Kangemi 4
3. Highridge H/C (CLOSED)
4. Karura H/C Location: Kiambu rd. next to Muthaiga golf club 2
5. Lady Northey H/C Location: State House rd. 2
6. State House. Clinic Location: State House 2
7. Kabete Approved Sch. H/C Location: Kabete Approved Sch 2
8. State Hse. Dispensary Location: State Hse Girls school 2
9. Lower Kabete Location: Lower Kabete 2
10. MjiwaHuruma Disp. Location: MjiwaHuruma, Runda 2
11. KARI 9Muguga) H/C Location:Muguga, Naivasha Road 2
79
12. Waithaka H/C Location: Waithaka suburb 2
13. Riruta H/C Location: Riruta shopping centre 2
14. Ngong Rd H/C Location: Karen 2
15. Woodley Clinic Location: Woodley estate MugoKibiru rd. district
facilities satellite clinic
2
16. Dagoreti Approved Sch. h/C Location: Dagoreti Approved Sch 2
17. Langata H/C Location: Otiende estate 2
18. Jinnah Clinic Location: Langata 2
19. Karen H/C Location: Hardy, Karen 2
20. Kibera DO H/C Location: DC’s office 2
21. Langata Women Prison H/C Location: Langata Women Prison 4
22. Nairobi West Prison H/C Location: Nairobi West Prison 3
23. Uhuru camp H/C Location: Uhuru AP camp 2
24. Kibera DO H/C Location: Kibera slums 2
25. KiberaAmref H/C Location: Kiberalaini Saba 2
26. GSU Kibera H/C Location: GSU Kibera quarters 4
5. EMBAKASI
1. Kayole 1 H/C Location: Kayole 1 estate 2
2. Kayole II H/C Location: Kayole II estate 2
3. Umoja H/C Location: Umoja II estate 2
80
4. Embakasi H/C Location: Embakasi village 2
5. GSU Embakasi H/C Location: GSU Training School 3
6. APTC Embakasi H/C Location: APTC Embakasi 3
6 NJIRU
1. Dandora 1 H/C Location: Dandora 1 estate, Komarok road 2
2. Dandora 11 H/C Location: Dandora II estate 2
3. Njiru H/C Location: Njiru shopping centre, Kangundo rd. 2
4. Kariobangi South Disp.Location: Kariobangi South estate 2
7. MAKADARA
1. Makadara H/C Location: Jogoo rd., Hamza estate 3
2. Mbotela Location: Mbotela estate, jogoo rd. 3
3. Jericho H/C Location: Jericho Lumumba estate 3
4. Hono Clinic Location: Hono Crescent Jericho 2
5. Ofafa 1 Clinic Location: Ofafa 1 2
6. Maringo Clinic Location: Maringo 2
7. Loco H/C Location: Nairobi Railway Station, Industrial area 2
8. MOW Dispensary Location: MOW sports club 2
9. Kaloleni Dispensary Location: Kaloleni estate shopping centre 2
10. Railway training Institute (South B) Dispensary Location: Railway
training Institute (South B)
2
11. South B Clinic Location: South B, next to shopping centre 2
12. Police Band Dispensary Location: South C 2
81
13. LungaLunga H/C Location: LungaLunga informal settlement 2
14. Nairobi remand Home H/C Location: Industrial area 3
Totals 169
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