Kenneth Munge

Seye Abimbola and co-authors argue for a transformation in global health research and practice in the post-COVID-19 world.

Background: Kenya has committed to achieve universal health coverage (UHC) and prioritised purchasing reforms. Existing evidence indicates that purchasing can be leveraged to achieve health system objectives when done strategically. However, no single study has collated evidence on the progress and bottlenecks on strategic health purchasing (SHP) in Kenya to inform requisite SHP reforms in moving towards UHC. Against this backdrop, we assessed the progress and gaps in SHP in Kenya. Methods: We used a cross-sectional qualitative study design and collected data using document reviews, key informant interviews, and a stakeholder engagement workshop focussing on the three main purchasers in Kenya: the National Hospital Insurance Fund (NHIF), county departments of health (CDOH) and the Ministry of Health (purchaser for vertical programmes). Data was analysed following a framework analysis approach. Results: Kenya is making progress towards developing, implementing and institutionalising SHP practices that should lead to the attainment of health system goals. Progress has been made in 1) strengthening the process of defining a health benefits package available for the population, 2) engaging in selective contracting and integrated care contracting, 3) implementing multiple provider payment mechanisms, 4) designing legal and regulatory frameworks that provide direction for purchasing, and 5) increasingly utilising information systems. However, several gaps remain. First, there remain inadequate linkages between MOH policies and the NHIF that can facilitate adequate stewardship/oversight. Second, the purchasers lack adequate capacity to ensure quality assurance and enforce contracts. Third, provider payment methods (PPM) remain poorly designed, implemented, and are not adequately linked to health system goals. Finally, purchasers have weak or unclearly defined communications strategies to patients and providers. Conclusions: Although Kenya is making progress in SHP, key gaps remain. Consequently, there is a need to implement reforms that will align the purchasers’ actions and decisions to the ideals of strategic health purchasing.

As more countries move from low- to middle-income status, they are perceived as increasingly capable of financing their own health systems. Some donors have begun to transition their support out of such middle-income countries (MICs) to redirect their funds to countries with greater needs. However, this transition may leave a funding gap for MICs that could be difficult to fill when external resources decline. If not carefully managed, such financial shifts could lead to the loss of health gains that occurred while receiving substantial external financial support. Understanding levels of donor dependency (i.e., whether or not a country is likely to have capacity to fill a funding gap caused by donor transition) and donor concentration (i.e., when only a few donors make up the majority of aid) can illuminate areas of potential vulnerability for transition. In this study, we analyzed Kenya’s health system for donor dependency and donor concentration.

To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries. Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies. Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied. We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.

Despite increasing adoption of unattended automated office blood pressure (uAOBP) measurement for determining clinic blood pressure (BP), its diagnostic performance in screening for hypertension in...

Summary: Objective: To estimate the direct and indirect costs of diabetes mellitus care at five public health facilities in Kenya.Methods: We conducted a cross‐sectional study in two counties where diabetes patients aged 18 years and above were interviewed. Data on care‐seeking costs were obtained from 163 patients seeking diabetes care at five public facilities using the cost‐of‐illness approach. Medicines and user charges were classified as direct health care costs while expenses on transport, food, and accommodation were classified as direct non–health care costs. Productivity losses due to diabetes were classified as indirect costs. We computed annual direct and indirect costs borne by these patients.Results: More than half (57.7%) of sampled patients had hypertension comorbidity. Overall, the mean annual direct patient cost was KES 53 907 (95% CI, 43 625.4‐64 188.6) (US$ 528.5 [95% CI, 427.7‐629.3]). Medicines accounted for 52.4%, transport 22.6%, user charges 17.5%, and food 7.5% of total direct costs. Overall mean annual indirect cost was KES 23 174 (95% CI, 20 910‐25 438.8) (US$ 227.2 [95% CI, 205‐249.4]). Patients reporting hypertension comorbidity incurred higher costs compared with diabetes‐only patients. The incidence of catastrophic costs was 63.1% (95% CI, 55.7‐70.7) and increased to 75.4% (95% CI, 68.3‐82.1) when transport costs were included.Conclusion: There are substantial direct and indirect costs borne by diabetic patients in seeking care from public facilities in Kenya. High incidence of catastrophic costs suggests diabetes services are unaffordable to majority of diabetic patients and illustrate the urgent need to improve financial risk protection to ensure access to care.

Summary: Background: Hypertension in low‐ and middle‐income countries, including Kenya, is of economic importance due to its increasing prevalence and its potential to present an economic burden to households. In this study, we examined the patient costs associated with obtaining care for hypertension in public health care facilities in Kenya.Methods: We conducted a cross‐sectional study among adult respondents above 18 years of age, with at least 6 months of treatment in two counties. A total of 212 patients seeking hypertension care at five public facilities were interviewed, and information on care seeking and the associated costs was obtained. We computed both annual direct and indirect costs borne by these patients.Results: Overall, the mean annual direct cost to patients was US$ 304.8 (95% CI, 235.7‐374.0). Medicines (mean annual cost, US$ 168.9; 95% CI, 132.5‐205.4), transport (mean annual cost, US$ 126.7; 95% CI, 77.6‐175.9), and user charges (mean annual cost, US$ 57.7; 95% CI, 43.7‐71.6) were the highest direct cost categories. Overall mean annual indirect cost was US$ 171.7 (95% CI, 152.8‐190.5). The incidence of catastrophic health care costs was 43.3% (95% CI, 36.8‐50.2) and increased to 59.0% (95% CI, 52.2‐65.4) when transport costs were included.Conclusions: Hypertensive patients incur substantial direct and indirect costs. High rates of catastrophic costs illustrate the urgency of improving financial risk protection for these patients and strengthening primary care to ensure affordability of hypertension care.

Strategic purchasing can ensure that financial resources are used in a way that optimally enhances the attainment of health system goals. A number of low- and middle-income countries, including Kenya, have experimented with micro health insurance (MHIs) as a means to purchase health services for the informal sector. This study aimed to examine the purchasing practices of MHIs in Kenya. The study was guided by an analytical framework that compared purchasing practices of MHIs with the ideal actions for strategic purchasing along three pairs of principal-agent relationships (government-purchaser, purchaser-provider and citizen-purchaser). The study adopted a qualitative descriptive case study design with 2 MHIs as cases. Data were collected through document reviews (regulation, marketing materials, websites) and semi-structured interviews with key informants (n = 27). The regulatory framework for MHIs did not adequately support strategic purchasing practice and was exacerbated by poor coordination between health and financial sectors. The MHIs strategically contracted health providers over whom they could exercise bargaining power, sometimes at the expense of quality. There were no clear channels for beneficiaries to provide timely feedback to the purchaser. MHIs premium payments were family-based, low-cost and offered limited benefits. Coverage was based on ability to pay, which may have excluded low-income households from membership. Adequate policy, legal and regulatory frameworks that integrate MHIs into the broader health financing system and support strategic purchasing practices are required. The state departments responsible for finance and health should form coordinating structures that ensure that MHI’s role in universal health coverage is owned across all relevant sectors, and that actors, such as regulators, perform in a coordinated manner. The frameworks should also seek to align purchasers’ relationships with providers so that clear and consistent signals are received by providers from all purchasing mechanisms present within the health system.

Summary: Background: Purchasing in health care financing refers to the transfer of pooled funds to health care providers for the provision of health care services. There is limited empirical work on purchasing arrangements and what is required for strategic purchasing in low‐ and middle‐income countries. We conducted this study to critically assess the purchasing arrangements of the county departments of health (CDOH) who are the largest purchasers of health care in Kenya.Methods: We used a qualitative case study approach to assess the extent to which the purchasing actions of the CDOH in Kenya were strategic. We purposively sampled 10 counties and collected data using in‐depth interviews (n = 81), focus group discussions (n = 4), and documents review. We analyzed data using a framework approach.Results: County departments of health did not practice strategic purchasing. The government's (national and county) role as a steward for the purchasing function was characterized by poor accountability and inadequate budgetary allocations for service delivery. The absence of a purchaser‐provider split between the CDOH and public health care providers undermined provider selection based on performance and quality. Poor public participation and ineffective complaints and feedback mechanisms limited public accountability and responsiveness to the needs of the people.Conclusion: Our findings show that while there are frameworks that could promote strategic purchasing of the CDOH, strategic purchasing is impaired by poor implementation of these frameworks and the inherent weaknesses of a public integrated purchasing system that lacks purchaser‐provider split.

Background Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries (LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the National Hospital Insurance Fund (NHIF) as a case study. Methods We applied a principal-agent relationship framework, which identifies three pairs of principal-agent relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through document reviews (statutes, policy and regulatory documents) and in-depth interviews (n = 62) with key informants including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers. Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed using a thematic framework approach. Results The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting, monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist, they do not always function appropriately and awareness of these channels to the beneficiaries is limited. Conclusion Addressing the gaps in the NHIF’s purchasing performance requires a number of approaches. Critically, there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the multiplicity of actors given Kenya’s devolved context. Relatively recent decentralisation reforms present an opportunity that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal health coverage (UHC).