Master of Science in Health Systems Management

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Factors that would influence the utilization of healthcare services by KeMU Nairobi campus undergraduate degree university students.
(KeMU, 2012-07) Muturi, Lucy W. Njogu
The Kenya healthcare system has been making varied efforts towards improvement. Utilisation of healthcare services continues to be a concern, with the need for interventions that can strenghthen the current weaknesses. Accepted models of healthcare service utilisation may not apply to university students due to their unique socio-demographic characteristics and health challenges. This study focussed on the service delivery pillar of health systems. The absence of a healthcare facility in KeMU-Nairobi campus that can cater for the healthcare needs of the students, remains a weakness in the service delivery pillar and hence an area that needs strengthening. The purpose of this study was to establish the factors that would influence the utilisation of healthcare services by undergraduate degree students if a facility were to be availed at the campus. The Andersen and Newman framework (1995) of health service utilisation was used as the theoretical framework. The objectives were to investigate the need, enabling and predisposing factors that influence the utilisation of healthcare services by undergraduate degree university students at KeMU Nairobi Campus. This was a cross-sectional study with qualitative and quantitative aspects. Random sampling was used to select respondents from the various degree courses. Systematic sampling was used to arrive at the required sample size. Respondents were 390 undergraduate degree university students at KeMU Nairobi Campus. Data was collected using pre-structured and pre-tested questionnaires. Data was analysed using a logistic regression mode of analysis which was done using SPSS version 17. The undergraduate degree student utilisation model designed by this study established nine predictors of utilisation of healthcare services by this target group. These were: need factors - awareness of services offered by the institution, purpose of utilising healthcare services; enabling factors — location of a healthcare facility, availability of healthcare services and source of income; predisposing factors — gender, marital status, academic performance, and interruption of academics due to health related reasons. The respondents had a 1.4 chance of utilising healthcare services if they were aware of the existence of the services and the facility; 78% of the respondents sought services when sick or in the event of an emergency; 63% of the respondents were concerned about the availability of health services; those who were self employed had an odds ratio of 0.32 of utilisating healthcare services; 61% of the respondents were female; 73% of the respondents were single; 52% of the respondents were students who got at least a grade of B+ and above; and 92% of the respondents had their studies interrupted due to healthcare related reasons. Conclusions of this study were that the students' population would specifically seek healthcare services when sick or in the event of an emergency; location was a key influence of utilisation of healthcare services; those who were not married had a higher chance of seeking healthcare services, and were not particular about which type of physician they saw. This study recommended that deliberate efforts must be made to create awareness of services that would be offered at the healthcare facility that would be established for the students population at KeMU Nairobi campus; the healthcare facility should be located in an area that can be easily accessed by the student population; and that there should be training and counselling services offered on student-work-life balance at the healthcare facility that would be set-up for the students.
External and internal factors affecting management of hospital drug formularies by health facilities in Nairobi
(KeMU, 2012-07) Njeru, Nancy Mucogo
The use of formularies in drugs management is a widely accepted practice and Kenya has adopted the World Health Organization (WHO) drug formulary model to develop its own formularies or essential drug lists. This study explored factors affecting management of drug formularies by both private and public health facilities in Nairobi. Specifically, the study sought to determine the type of formulary in use by various health facilities in Nairobi as well as exploring extents to which both identified external and internal factors influence the management of drug formularies in the said health facilities. A cross-sectional descriptive study was employed where the researcher used stratified random sampling as well as convenient sampling to draw a sample of 189 health facilities from the population. Results: There is 94% awareness of drug formularies, only 41.8% have participated in development of an Standard Treatment Guidelne or a drug formulary. 71.4% of respondents considered drug formularies very important. 73.5% of registered health facilities in Nairobi have adopted the Kenya Essential Ddrug List (KEDL). Out of the 73.5% above, 49.2% of the facilities have developed facility own drug formularies while 26.5% confirmed to not have used the national essential drug list at all. All ministry of health local authority facilities used the National essential drug list. Majority, 93.6% considered their formularies open while only 6.4% considered their formularies closed. Drug promotion poses the greatest influence to drug formulary non compliance while insurance was considered the least external factor in Nairobi health facilities. Under internal factors, lack of pharmacy and therapeutic committees or its equivalent topped the most challenging internal factor affecting the drug formulary availability and compliance. Conclusion: Drug formulary mangement in Nairobi health facilities is not fully developed and is also facing alot of challenges. Recommendations: There is need to base all facilities-own formularies on set standards while exploration of higher levels of formulary management will ensure more benefits to patients. Individual facilities must be more proactive in ensuring they operate within the national medicine policies which is possible through self regulation. Pharmacy and Therapeutic Committee in facilities to be enforced and also for health centres and dispensaries on need basis.
Critical review of training process towards strengthened service delivery in Dagoretti sub-county.
(2015-05) Maina, Lydiah wairimu
Human resources are the most important assets of any health system. Training is one of the principal means by which health professionals such as Nurses and Clinical Officers maintain, improve, and broaden the knowledge and skills required. Despite progress in developing more effective training methodologies, training initiatives for health workers continue to experience common pitfalls that have beset the overall success. To improve the quality of healthcare services, the shortage of healthcare workers must be addressed by giving quality training and education needed to fill the gap to increase the output of qualified healthcare workers. The study area was in Dagoretti Sub County and 7 facilities were selected owned by the Ministry of Health and the County Government namely Mbagathi District Hospital, Dagoretti Sub County Hospital, Riruta Health Center, Waithaka Health Center, Ngong Road Health Center, Chandaria Health Center and Woodly Clinic. The sample size was 170 Nurses, 50 Clinical Officers, 6 Facility in Charges and 14 Sub County Managers. The research study examined the training process: Selection criteria; Follow up mechanism; and Coordination of activities and how this could strengthen service delivery. The study followed a descriptive cross sectional study design. A survey method using structured questionnaires for facility in charges, nurses and Clinical Officers and a key informant interview was conducted for the sub county managers. Sampling technique used was convenient sampling method. The reaction to the study was positive with a questionnaire response rate of 75.1%. Data analysis included identifying and comparing findings using Statistical Package for Social Scientists software. Data was presented using APA tables, pie charts and bar graphs. The results of the study showed that selection criteria could influence training process by 44.6% at a significance level of 0.03, follow up mechanism could influence training process by 58.4% at a significance level of 0.01 which is very significant and coordination of training activities could influence training process by 43.1% at significance level of 0.03. The findings revealed disconnect between sub county managers, facility in charges, nurses and Clinical Officers on how the training process is carried out. The study concluded that selection criteria is not need based; there is no data base of trainings held. Follow up mechanism is not in place and action plans are not implemented. The activities coordinating training are not well defined since there is no information on trainings available. Based on the conclusions, the recommendations made are improving Human Resource Information System; establishing a training schedule; and a system to evaluate service delivery. This would strengthen the Human Resources for Health pillar and the service delivery pillar in Health system strengthening.
Factors affecting clinical teaching for pre-service nursing education in Kenya medical training college, Nairobi campus.
(KeMU, 2015-06) Mwatsahu, Francis Gwama
Training of health workforce is an important element in ensuring delivery of quality health care services. New options for the education and in-service training of health care workers are required to ensure effective preparation and to meet a country's needs. Nursing education in Kenya has faced challenges of shortage of qualified clinical faculty. Over the past five years, there has been a tremendous expansion in nursing education with the colleges offering nursing education and the number of students rapidly increasing. The rapid expansion in nursing education has not been complimented with concurrent increase in the facilities nor the number of available clinical nursing lecturers. This has raised concerns on the effects of faculty shortage on the quality of clinical teaching for pre-service nursing education and ultimately nursing practice. The aim of this study was to assess factors affecting clinical teaching for pre-services nursing education in KMTC, Nairobi Campus. Specific objectives included: to determine the capacity of nurse tutors in clinical teaching for pre-service nursing education, establish the institutional factors affecting clinical teaching for pre-service nursing programme and investigate the quality of clinical teaching methods employed in the pre-service nursing education. Cross-sectonal descriptive study design was adopted. The sample size was 132 comprising of 5 nurse tutors, 7 clinical instructors, 20 nurses and 100 student nurses. Purposive sampling was used to sample the student nurses, while census was used to sample nurse tutors from KMTC, Nairobi campus. Self-administered questionnaire, interviews and record reviews were used for data collection. Data analysis was done using SPSS. The study findings show that majority 23 (72%) of nurse educators were diploma holders and most 25 (78.1%) didn't have any additional training besides the basic nursing education. Most 12 (37.5%) of nurse educators have 2-4 years of experience as nurses or clinical intructors. The numbers of nurse educators were generally low with a nurse instructor to student ratio of 1:10 in placement facilities. 125 (95%) of all respondents agreed that demonstration was the most preferred teaching method for clinical instruction. In addition, 125 (95%) respondents said that experience had the most influence on clinical training. 115(85%) felt that generally health facilities were not adequately prepared to support clinical teaching for pre-service nursing education. The study recommends that: KMTC should enforce policies that ensure nurse tutors have adequate academic qualifications and experience, which correspond to clinical teaching for nursing education; KMTC should work with trainees' health facilities placement, to ensure that there are adequate facilities to support effective clinical training for pre-services nursing education in Kenya; KMTC should review it pre-service nursing curriculum to ensure that it responds to contemporary issues in the nursing professional and KMTC should organize regular on job trainings to update nurse tutors on curriculum contents as well as teaching methods, with an emphasis on clinical skills training. Key words: Clinical training, pre-service, nursing education, Kenya Medical Training College, Kenya.
Implementation of adolescent friendly health services in county referral hospitals.
(KeMU, 2015-06) Owuondo, Pacific Akinyi
Health service delivery is a key pillar of the health system management .The World Health Organization recently emphasized the need to develop adolescent -friendly health services to improve the care provided to young people throughout the world. However, there is limited peer reviewed literature on this subject therefore necessitating assessment of whether the existing health facilities are prepared to implement the adolescent friendly health services. Adolescent friendly health services remains a relatively new and sensitive area mainly due to restrictive norms and policies guiding the services. After International Conference on Population and Development in 1994, countries started implementing adolescent friendly health services. The Government of Kenya together with partners in an attempt to address the health challenges came up with the Adolescent package of care (APOC) in 2013 whose guidelines were finalized in November 2014 and released for use by service providers. Despite this package of care, there is still ineffective staff capacity in relation to skills and knowledge gap of health professionals, training needs, health resources as well as health system factors that can affect implementation of AFHS. The study explored ways of mitigating or addressing the barriers to implementation of these services. The study used both quantitative and qualitative approaches to collect data. The study utilized survey research adapting descriptive cross sectional design and semi-structured questionnaire to interview 348 health care providers and 472 adolescents in Mam Lucy Kibaki Hospital from 3rd May 2014 to 16 June 2014 .The respondents were mainly nurses, clinical officers and Medical doctors who were working at the health service delivery area at the time of study and were interviewed using an interview guide. The managers at the hospital were interviewed using an in-depth interview guide while the adolescents were interviewed through interview schedule. A total of four (4) focus group discussion was held with adolescents. Quantitative data was analyzed using SPSS Version 18.0. Descriptive statistics and chi-square tests were performed to determine significant associations. The study established that sex, age, level of education and adolescent awareness about existence of friendly health services offered were significantly associated with utilization at p<0.05. Long queues, unfavorable working hours and lack of money negatively affected consumption of AFHS. The study concluded that the utilization of health services among the adolescents was low largely due to unfriendliness of the health care providers at health facilities and lack of awareness of AFHS services. In view of the findings, this study recommends need for the Government through the Ministry of Health and partners in health service provision to increase the number of AFHS and ensure that the recommendations of adolescent package of care is implemented fully with good evaluation strategies in place. Laborious awareness drives to sensitize the adolescents about availability of adolescent friendly services through rigorous health education and increased involvement of both parents/guardians and teachers to scale up implementation are also recommended. Keywords: Preparedness, Staff Capacity, Health resources and Adolescent friendly Health Services.
Community health information system utility.
(2015-12) Pepela, Wanjala David
A wealth of data is available within the healthcare systems more so at community level. However, lack of effective use of information shared during dialoguing at the community level in Bungoma County posed a great challenge despite efforts by government in recognising community care services as critical level 1 service. Health indices have remained on a worsening trend with service utilisations very low. The purpose of the study was to inform service utilisation, promote use of community health information to improve health outcomes. The main objective was to determine the community health information system utility to improve health outcomes in Bungoma County. The specific objectives were to assess the community units level of use of information processes for improved community health services; to identify the technical tools for sharing information during community dialogue and action days; establish community health information system capacities affecting sharing of available information and determine what organisational factors influence sharing and use of community health information. The study was descriptive cross-sectional design. The study employed a combination of stratified clusters proportionate to population size and applied simple random sampling technique with a proportion of 30% of target population as representative sample. The target population was (N =163) with a sample size of nh =54 community units. A structured interview questionnaire both closed and open-ended was administered to Community Health extension workers and 3 in-depth focus group discussions. Data analysis generated univariate frequencies and interpretation using tables and charts. The expected outcome was utility of health information. Results showed that response rate 44 (81.5%), 35 (79.5%) with knowledge on data management and 39 (88.6%) generated monthly summaries with 34(77.3%) with overall utility of community information using white/chalkboards. 27(60.6%) provided feedback and shared information during dialogue days monthly at 41(93.2%) and 17(38.6%) respectively. Information had inadequate involvement in design 14(32%), unavailability of data tools in 39(89%) and less use of appropriate technologies. 26(59.1%) had knowledge on kind of information required, 27(61.4%) analysed this information while, 42(95.5%) used information for evidence based-decision making. Income generating activities supported by partners in 6(13.6%) of the units. Community formal structures was in 32(72.7%) units and shared information in dialogue 54(100%), 36(81.8%) using "Barazas" while, 31(70.5% through health promotion and education. Majority 40 (90.7 %) were empowered through support supervision using standard procedures and checklists. Regression analysis using ANOVAa showed that results were moderately correlated with utility of community information with correlation Coefficientsa 0.017 at 13 0.538b, while Pearson Chi-Square Tests compared with use of information with linear association of 0.910 had a likelihood ratio of Fisher's Exact Test of 0.658 thus, result moderately significant. In conclusion knowledge was above average; information was regularly shared through community dialogues; while design, technical tools and empowerment of communities were weak and inadequate and finally the system was well structured though not resourced and uncoordinated. It was recommended that both National and County governments to emphasize on regular feedback to promote information utility; adequately provide technical capacities and mentorships;
Data quality of routine health management information system.
(2015-12) Cheburet, Samuel Kiprono
Effective and efficient management of today's health system depends on well-functioning Health Management Information System (HMIS) in design and implementation. Good quality data are the foundation of health systems in generating information for policy-making, planning, monitoring of health outcomes and evidence based decision making. Taking the cognizance of deficiencies in data quality, where vital health decision often depend on political speculation, donor demand and studies which are insensitive to changes over time. The aim of the study was to contribute to improvement of data quality of Routine Health Management Information System to facilitate efficient and effective decision making in Uasin Gishu County Hospital and possibly in similar settings. The objectives were; to assess the current state of data quality of routine health management information system; to determine socio-demographic characteristics that affect data quality of routine health management information system; to identify process factors influencing data quality of routine health management information; to find out technological factors affecting data quality of routine health management information system and to establish organizational factors influencing data quality of routine health management information system in Uasin Gishu County Hospital. This was a cross-sectional study which adopted quantitative and qualitative approaches. The study used purposive sampling to select study site with a target population of 82 respondents. Data extraction form, structured questionnaire and key informant interview guide were used for data collection. Questionnaire results were edited, coded, tabulated and analyzed using SPSS Version 23, StataSE version 13 and Microsoft excel. The results showed availability of data were at 88 (56%). 32623(44%) of the data elemets in all the reports dully filled. The reliability of data using Cronbach's Alpha were at .729. which fall within acceptable value and 48(16%) marginal error. 65(80%) of respondent are permanent and pensionable, 55(68%) staff who collect data are nurses. 81(100%) had gone for leave while 61(75%) found pending work. 38(47%) knew RHMIS through workshops while 78(96%) participate in data collection and 51(63%) had not been trained on HMIS while 37% (30) had been trained in the last 12 months of the year 2014. 69 (85%) had responsibilities while 53 (65%) were able to accomplish the task (x 2 = 26.665, df=1, p=0.000), 32 (40%) affirmed availability of standard operating procedures with 0% availability of quality protocol with an index of 18% institutional documentation. In conclusion the study found that current data quality from routine health management information system had major gaps if used to generate information and recommended the need for advocacy for continuous information use as a culture; data review and verification. The Ministry of Health require to advocate for increased human resource in terms of numbers and skills which has implications on the process factors. There is also need to ensure continuous supply of data collection tools with minimum datasets. . Stakeholders should strengthen capacity building through mainstreaming HMIS into various professional curriculums and strengthening of institutional documentation especially policy, standard operating procedures, guidelines and data quality protocols to enhance data quality.
Diagnosing information culture among healthcare Service providers in Machakos county, Kenya
(KeMU, 2016) Auma, Kennedy Odhiambo
Good health services are those characterized by distinctive information cultures. It is unmanageable to systematically describe the information culture of an organization. This study was carried out to establish the information culture cultivated. The objectives of the study sought to systematically describe information technological practices, information management practices, resources and behavior values that can characterize the desired information culture of an institution, and whether this culture has an effect on information demand and use. A cross-sectional, descriptive method was utilized, adopting qualitative and quantitative data collection approaches. 235 respondents were selected using stratified proportionate sampling method in the five purposively selected public hospitals participated in the survey. The primary methods of data collection comprising both semi-structured questionnaire for the survey and an interview schedule. Data was collected by a structured validated and reliable (r = 0.8) questionnaire and an interview schedule, after a completed consent from the subjects. Data analysis using SPSS Version 22 was carried out and results presented in graphs, charts and mostly inferential statistical tables. It was established that usage of information was average as the highest average was 55.0%. Females were 119(68.8%) compared to their male counter parts who had 54 (31.2%) respondents. There were 114(65.9%) diploma holders, who were the majority with those attaining masters at 7(4.0%). Machakos hospital (24.2%) has the highest number of those with Masters at 22 respondents, while Kathiani (7.7%) had the least at 2 respondents. Most of the respondents (23.1%), were aged between 26-30 years, followed closely (21.4%) by ages 31-35. On comprehensiveness of the information, all four health facilities had high as Machakos county hospital recording the highest average 73 (80.1%) and while Matuu sub county hospital had an average of 16(61.3%). Chi square tests showed significant relationships between having written roles, supervisions, and responsibilities, and ability to share data generated. The p-values for the 4 health facilities were carried out at 5% level of significance and the results are presented in the Table 4.5. On the aspect of usability, it was significant in only two health facilities i.e. Machakos and Matuu (p<0.05) while comprehensiveness was significant among all the four health facilities (p<0.05). Resource utilization was significant in three health facilities i.e. Kangudo, Machakos and Matuu (p<0.05) as compared to motivation, which was significant in two health facilities i.e. Machakos and Matuu (p<0.05). Inaddition, supervision was significant in three facilities i.e. Kangundo, Machakos and Matuu (p<0.05). The use of policy & guidelines, information management (both explicit and tacit) were all significant in all the four health facilities. A significant relationship was found between usability and motivation of staff and accuracy and comprehensiveness of patient information. It was concluded that, key factors that affect information practices, attitudes to information management, and information flows should be identified and managed as these would spur good information culture that is key in service provision. Recommendations were to improve health information system training, improve support supervision and enhance the underpinnings for decision-making. Further research to explore the effects of electronic health records (ERR) on patient information management was recommended.
Implementation of Kenya quality guidelines for efficient delivery of health care services.
(KeMU, 2016-06) Owiti, Winnie Sarah
Quality is a key principle in health service delivery a pillar in health systems strengthening. The Kenya Quality Model of health was initiated across all health facilities to guide the implementation of quality standards. The Kenya quality guidelines are guidelines for defining, measuring and improving performance of health services across different care facilities that targets organizations and clinical leaders. Despite having, guidelines there are disparities in the quality of services delivered at Kakamega County. The objectives of the study were to determine the comprehensiveness of quality guidelines implementation in Kakamega County, to establish the institutional factors of quality guidelines implementation, to establish the human resource for health factors of quality guidelines and to establish management practises of quality guidelines implementation. In a cross-sectional design, 127 clinical managers in 6 public health facilities were selected using random sampling of public health facilities, stratified and proportionate sampling of clinical managers. Data collection was through interviewer administered closed ended questionnaires and key informants schedule. SPSS version 22 was used to analyze data in frequency distributions and percentages. To determine the profile of respondents and quality guidelines implementation, institutional factors and human resource factors were analyzed using means scores, standard deviations and Anova one way. Clarity of quality guidelines had a mean score of 3.3 and objectives a mean score of 2.2. Most respondents indicated that guidelines were unavailable since most of them were kept on shelves (48%), the services that implemented the guidelines included HIV services with mean 3.7, medical services 3.6, nursing services 3.3 and pharmacy 3. The human regource for health factors that affected implementation of guidelines were awareness of guideline contents 3.7 and motivation 3. The management practices used to implement guidelines were steps in quality management with mean 3.8, planning 3.3 and use of data 3. Monitoring and evaluation was done by health workers 40 (36%) using check lists 48(40%). The findings on quality guidelines comprehensives had P-Value of 0.231 indicating no significant relationship between comprehensiveness of quality guidelines and improved health services. For institutional factors the P-value was 0.32 indicating a relationship between institutional factors and improved health services, human resource for health P-value there was 0.033 which indicated a relationship between human resource for health and improved services. Management practices P-value was 0.042 indicating a significant relationship with improved quality of health services. The study recommended formulating a policy that can be used to train human resource before implementing guidelines, sensitizing all services to implement quality guidelines and establishing strong quality teams and developing quality implementation monitoring tools. The study further recommends development of customer satisfaction feedback form to daily monitor quality of health services
Factors influencing uptake of maternal health services initiatives among mothers: a case study of Nakuru-Kenya.
(2016-06) Wairia, Samuel Kingori
Strengthening health Service delivery is very important in improving maternal mortality which remains an urgent problem to be addressed in developing countries around the world. Kenya has a very high maternal mortality rate which stood at 471 per 100,000 live births compared to other developing countries of 230 per 100,000 live birth and 16 per 100,000 in developed countries while Nakuru County had a maternal mortality rate of 374 per 100,000 live births despite being one of the counties with the best infrastructure, high number of health workers and better health care financing. This revelation is an indication of an ineffective health systems leading to poor uptake of MHS. The broad objective of this study was to assess factors influencing uptake of maternal health services initiatives among mothers in Nakuru County. The specific objectives were: to determine if the clients characteristics influenced uptake of maternal health initiatives, to assess levels of awareness of maternal health initiatives and to establish if the organization of health services influenced uptake of maternal health services in Nakuru County. The study was undertaken in Nakuru County between January and April 2015. The study was a cross-sectional in design where both qualitative and quantitative approaches were used. A total of fifteen level 4 hospitals (9 private and 6 public) were purposively selected for the study. The sample size was obtained by use of Cochran 1963 formula where 233 mothers were included in the study as respondents and sampled using systematic sampling and purposive sampling was used 8 health workers who were in-charge of MCH services in their respective facilities, these were included to be part of a focus group discussion (FGD). The data was collected using semi structured questionnaires for mothers and FGD guide. Quantitative data was analyzed using SPSS version 20 and presented in tables, percentages and pie charts while Qualitative data was analyzed using excel sheet software. To understand the relationship between variables, inferential statistics was done using Chi-square Test and P-values obtained. The response rate was 233(100%). The finding of the study indicated that a client's characteristics like age, education, religion, marital status and employments have significant influence on the uptake of MHS and the level of education was the best predictor of uptake of MHS initiatives, mothers had low levels of awareness of MHS initiatives with the least being in emergency obstetric care (EmOC) and free maternity services (FMS) which had a median of 1 (that is slightly aware). The least P-value was in free maternity services (P-value=.037). The poor organization of services affected the uptake of maternal health services especially due to acute shortage of staffs (that is hospitals operating below 50%), intermittent supplies of drugs, poor healthcare financing and services setup. In conclusion, client's characteristics influence uptake of MHS, mothers had low levels of awareness on MHS initiatives and poor organization of health services affect uptake of MHS. Therefore, the researcher recommended that :Community opinion leaders should be involved in decision making process to increase uptake/utilization of maternal health services among the low education class, door to door awareness campaigns especially of free maternity and emergency obstetric services be carried out within community through community own resource persons (CORPs) and Health facility management forums should be created to improve organizational approaches that will make services more user friendly to the community. Further Studies can be done on the impact of devolution of health services on access to maternal health services among mothers.
Factors influencing scaling up quality of referral processes in Kenya.
(KeMU, 2016-06) Chika, Agnes Akinyi
Scaling-up quality referral processes strengthens the health system. Referral refers to any process in which healthcare providers at lower levels of the health system seek the assistance of providers who are better equipped or specially trained to guide them in managing or to take over responsibility for a particular episode of a clinical condition in a patient. Quality in health care falls under Service delivery, which is one of the six key health system strengthening building blocks. The main objective of the study was to find out the factors influencing the scaling up quality of referral processes at Kenyatta National Hospital and the specific objectives of the study were to; establish how the management of referrals can scale up the quality of referral processes at Kenyatta National Hospital, determine how the pre-referral communication processes scale-up the quality of referral processes, and establish how referral staff can scale up quality of referral process. The Research design was a descriptive cross-sectional and retrospective study, data was collected using a questionnaire and check list. A check list was used and 384 referrals entered, a total of 100 self-administered questionnaires were completed by staffs working at Kenyatta National Hospital and returned. Data analysis was done using SPSS version 21 and presented in tables, bar graphs and pie charts, reliability was done to establish regression co-efficient at (95%) confidence interval. The findings revealed that majority of the respondents 80(79.8%) indicated the referring institutions do not understand the referral policy, guidelines and Standard Operating Procedures, 12(13.5%) showing that they know and 6(6.7%) indicating that they don't know, majority of patients, 75(75%) came with referral letters which were incomplete, 13(13.7%) lab results and 12(12%) coming with X-ray results. The findings indicates that 51(56%) of the referred patients came with nurse, 40(44%) relative with none being escorted by doctor. According to the findings 63(67%) of the referring hospitals did not call prior to referring the patient, only 31(33%) called before transferring the patient to KNH. In conclusion, the findings showed that there was significance relationship between referral policy and staff knowledge on referrals at P< 0.05 with chi square test of 0.004. Scaling up the referral processes ensures quality of referral services. The study recommends that the management of Kenyatta National Hospital needs to ensure that dissemination, sensitazation and awareness of the referral policy, guidelines and SOPs is done for the staffs both in the referring and receiving hospitals, referral tools, forms and registers be distributed at all levels of the health system for standardised information in the referral letters, laboratory and radiological investigations. Employ adequate human resource in the hospital.
Functionality of community-based health information systems in Embakasi sub-county, Nairobi County, Kenya.
(KeMU, 2016-07) Kaburu, Emily Wanja
A functional Community-Based Health Information System (CBHIS) is poised to collect, collate, analyse, evaluate, store, and disseminate community health-related data and information for use by the community. There is inadequate information available of what influences the functionality of CBHIS in Embakasi Sub-county. This is an impediment to informed strategies that can enhance focused improvement and maintenance of functional CBHIS. The main objective of the study was to assess functionality of CBHIS in Embakasi Sub-County, Nairobi County, Kenya. The specific objectives were: To determine the relationship between workers individual characteristics and functionality of CBHIS; to assess the internal factors that influence functionality of CBHIS and to assess the external factors that influence functionality of CBHIS. The target population was 10 functional Community Health Units (CHUs) in Embakasi sub-county. A sample size of 80 health workers from CHU and link health facilities was used. The study was descriptive cross sectional in nature where both qualitative and quantitative methods of data collection were used. The study adopted Key Informants interview, for link health facility workers, and 2 sets of questionnaires for CHU workers. The data acquired was analyzed using thematic analysis, MS Excel and Statistical Package for Social Sciences Software respectively and presented in frequencies, percentages, tables, charts and graphs. Relationship between the independent variables and the dependent variable was established using Chi-square test of association, fisher's exact test and Logistic regression models since the responses were categorical. A total of 68 respondents were interviewed with a response rate of 67%. There was a significant relationship between marital status, age of the Community Health Volunteers (CHVs), and ability to collect data at (p=0.024 and p=0.016 respectively). However, at a=0.05 there was no significant evidence linking gender and ability to collect data (p =0.637). Besides, at a=0.05 there was a strong relationship between experience and CHVs ability to understand indicators (p=0.033). There was no sufficient evidence linking CHV education level, age and understanding of indicators (p=0.696 and p=0.469 respectively). The tools, feedback forums, training and support supervision were available but inadequate and that CHUs did not have data analysis capacity. There was acute shortage of workers, inadequate tools and the reporting lines were not clear. The community was very supportive to CHUs activities and the linkages were effective as stated by all the respondents. However 3(60%) of the Community Health Extension Workers (CHEWs) pointed out that the county leadership was unsupportive to the CHUs while 2(40%) reported the county leadership supportive. The study recommends that CHUs functionality be reinstated in order to strengthen the functionality of CBHIS, HIS and the entire health system. Marital status, age and experience of workers should be considered when selecting the CHVs; the local leadership should provide the workers with adequate tools, capacity build them on data analysis, strengthen dialogue and action days, offer frequent refresher training and equip the workers with supervisory skills. Finally, the linkages between CBHIS and FHIS should be strengthened and that the local leadership should support the community health unit activities. The researcher proposed that further research be done to determine the role of Community-Based health data in strengthening decision making at the national and local level.
Drivers of Health Services' Sustainability in Selected Mission Hospitals in MT. Kenya
(KeMU, 2016-07) Ndege, Josephine Muthoni
Mission hospitals were initiated by missionaries and were heavily subsidized. The situation has changed; donor support is no longer reliable and cost of providing services has increased tremendously. The subsidy which enabled the services to be cheap and accessible has largely ceased hence the full cost of delivering services has to be met by the patients. A number of mission hospitals are befallen by crisis due to weak governance structures leading to poor oversight of health institutions. The health providers market has also become very competitive with private and public health units mushrooming in both urban and rural areas. Due to the financial constraints, sustainability of mission hospitals has been difficult and is in dire need of exploring other factors to enable it sustain health services. The study was conducted to explore drivers of health services' sustainability in mission hospitals so as to enhance service provision, accountability and growth while embracing best practices. The specific objectives were to find out if governance, continuous quality improvement and stakeholders engagement influence sustainability. The study was carried out in 10 faith based Hospitals in Kirinyaga, Murang'a, Embu, Nyeri and Meru counties with bed capacity of 60 and above. A descriptive cross sectional study design was used and a non-probability sampling method was used to select subjects of the study. Questionnaires and key informant interviews with selected chief executive officers was used to collect data that was analyzed using Statistical Package for Social Sciences and presented in the form of frequency tables at p < 0.05. A multivariate regression model was applied to determine the relative importance of each of the three variables with respect to Health Services' Sustainability. The study found out that mission hospital adheres to quality improvement practices such as presence of quality improvement teams and standard operating procedures but lacks top management support; they have a board of directors but lack a clear documented organization structure (organogram) while board composition was biased to church leaders. Study also indicated that stakeholder's engagement was a key drive to sustainability but there was little engagement within the catchment population. The study concluded that Mission hospitals lack sufficient funds from their sources of income to sustain quality health services since main source of funds is user fee which is also affected by dwindling patient numbers. The study recommends that Governance of mission hospitals should be strengthened and professionalized to ensure that it has the essential competence and Mix of skills and employees trained on sustainable procurement concept. It is recommended to further research on how mission hospitals can gain competitive advantage through service differentiation.
Human resource management practices on performance of health workers in public hospitals: a case of Mbagathi hospital, Nairobi City County.
(KeMU, 2016-07) Musyoka, Felistus Ndanu Musyoka
Sound human resources management practices are essential in strengthening the health systems. Human resource management practices like use of job descriptions, use of performance appraisal and use of supervision can transform health workers into a productive, motivated, and supported workforce capable of improving healthcare services and saving lives. Kenyan health system is designed such that human resource managers are based at county and national offices only and not hospital levels therefore the hospitals lack managers to champion human resource management practices at facility level. The specific objectives of the study were to determine the extent to which the practice of performance appraisal at Mbagathi Hospital (MH) influences the performance of health workers; To assess the level to which use of job descriptions at MH affect the performance of health workers; to examine the degree to which supervision practiced at MH contribute on performance of health workers; and to determine the challenges faced by health service managers on human resource management practices at MI-1. Mixed research design was applied in this study. The targeted populations were 22 health service managers and 275 technical staff. 11 health service managers were purposively selected to the study and stratified sampling was applied to sample 179 technical staff Research instruments were key informant interview guide for the health service managers and self-administered questionnaire for the technical staff. Data analysis from the self-administered questionnaires was done using SPSS 20 and results displayed on graphs, charts and tables. Analysis of the data from key informant interview guide was transcribed verbatim, coded and analyzed through content analysis. Results from quantitative data were triangulated with qualitative results. Responsiveness had a mean score of 56%, availability at 53.5%, productivity at 54.6%, and competency at 65.9%. The health workers performance was rated at a mean score of 57.6% with a standard deviation of 4.2%. The health service managers at the hospital were not aware of policies on human resource management practices. There were no trainings in the hospital on human resource management practices. Performance appraisal was minimally used (20.7%). Job description was moderately used (42.5%). Supervision was minimally used (36.4%). Health workers' performance was not significantly associated with use of perfonnance appraisal, existence of job description and use of supportive supervision. The MH management should embrace performance appraisal as a tool to motivate its health workers and improve its customer service rather than just using it to fulfil requirements by the parent ministry. Health service managers at MH require basic training on human resource management practices so as to be able to support heath workers in their daily activities and there is need to establish human resource management department to champion these practices.
Factors influencing the adoption of minimally invasive approaches during surgery amongst tier four hospitals in Nairobi County, Kenya.
(KeMU, 2016-07) Muchiri, Danson Mwaniki
Surgical service delivery is a key component in the service delivery pillar of the Health System. Due to the nature of resources required for surgical services, cost is a major concern for health systems and therefore it's difficult to discuss the delivery of good quality of surgical service without anchoring it in the financing pillar as well. Few health system facilities can afford to equip themselves for surgical services and as a result, there are is an overwhelming number of clients in the waiting lists for surgical services. Clear outlines of reasons for low uptake of these approaches are not available for use by decision makers hence no evidence based remedial actions can be taken as yet. The objectives of this study were to determine the influence of Institutional, Patient and Surgeon factors on the utilization of minimally invasive approaches to surgery in tier 4 hospitals of Nairobi County. A cross sectional survey was carried out in a population of 100 surgeons. A purposive sampling was done, 80 surgeons in two specialties namely General Surgery & Obstetrics Gynaecology who operate in tier 4 health facilities were subjected to questionnaires and key informant interviews. The data was collected for a period of five months yielding a 100% response rate and analysis done using SPSS version 23. A total of 9 surgical interventions emerged from the respondents as they were required to consider an intervention for which they had the option to use either of the two possible approaches-open and minimally invasive approaches. On a scale of 1 (least recurring) to 5(most recurring), Hospital not having the required devices/equipment and equipment being non-functional emerged as the most common impediments to MIS (mean score, 2.61) Hospital not having competent nurses came in second (mean score, 2.21). Hospital policies not encouraging adoption came in least (mean score, 2.10). For the patient related factors, Patient presentation-obesity, co-morbidities, age) emerged as the most prominent patient factor that leads to an open approach for a procedure (mean score 2.87) followed by intra-operative complications presentation (mean score, 2.80). Out of pocket came in third (mean score 2.60) while patient insistence was the least significant (mean score,1.71). Lack of confidence in the MIS approach for the cited procedure emerged as the most important consideration for surgeon related factor (mean score, 2.55). Surgeon preference followed (mean score The research concluded that the availability of functional enabling technologies was the most significant institutional factor in the adoption of MIS approaches. The absence of intra-operative complications and the surgeon's level of comfort in an approach emerged as the most significant for the patient and surgeon factors respectively. The research recommended the development of health economics driven budgets for enabling technologies, financing for surgical interventions and a review of surgical registrar training to incorporate MIS approaches for surgical procedures.
Health systems factors influencing utilization of essential health package in public hospitals.
(KeMU, 2016-07) Opon, Shadrack Ochieng
Availability of health care services does not guarantee that patients will optimally use them. In Homabay County, lack of access to health services is among the top reasons for low service utilization. This study focused on service delivery pillar and in particular the utilization of essential health packages (EHP), which include infectious diseases, maternal and newborn health, nutritional deficiencies and common injuries. According to Kenya Demographic Health Survey 2014, the health care utilization rate is 77% for those who are sick in Kenya. Among those who are ill and do not seek care, 44% and 18% were hindered by cost and distance respectively. The Health Sector Statistics Report also suggests that the overall child mortality rate is 121 per 1,000 live births. In Homabay County, child mortality rate is 91 per 1,000 live births, and maternal mortality rate is 583 per 100,000, compared to the national average of 488 per 100,000. The study assessed health systems factors influencing the utilization of EHP in public hospitals in Homabay County. Specifically, the study assessed how human resources for health, availability of drug, the role of health infrastructure, and organizational practices influence the utilization of EHP. The study adopted cross-sectional research design. Two hospitals were conveniently sampled (Homa-bay County Hospital and Mbita Sub-County Hospital) due to their large volume of patients. Yamane's formula was used determine the respondents' sample size. The study used stratified and simple random sampling methods to sample 138 health workers (Pharmacists 5, Clinicians 13, Health Management Information System Officers 8, Nurses 104, and Hospital Managers 8), and simple random sampling to sample 186 patients. Structured questionnaire and key interview guide (with 8 hospital heads) were used to collect data. Findings revealed that, all the health workers 138 (100%) said that Homabay County has shortage of health workers, the hospitals have inadequate drugs and patients are referred elsewhere due to lack of medical equipment. Majority 115 (83.3%) health workers say hospitals lack operational ambulances. Majority 153 (82.3%) and 135 (72.6%) of patients are hindered by cost and distance respectively to access health care. Among organizational factors, majority 159 (85.5%) patients do not always find all services they wanted and had ever failed to seek care because of the long waiting time. The regression model revealed at least 0.06 coefficients, indicating that a positive change in the independent variables (human resources for health, availability of drugs and supplies, health infrastructure, and organizational practices) results in a positive change in the dependent variable, utilization of EHP. Positive Pearson's correlation of 0.11 showed a close relationship between the variables. Conclusively, Homabay County lacks adequate health workers, drugs and hospital infrastructure, in addition to poor organizational practices leading to low utilization of EHP. The study recommends that the county employs more health workers, improves the procurement system, invests on health infrastructure including medical equipment, emergency ambulances, and buildings and should review costs of services to improve utilization of EHP in Homabay County.
Determinants of availability of tracer essential medicines in public health facilities in Nyeri County, Kenya
(KeMU, 2016-07) Kawira, Micheni Stella
The goal of the health system is to improve health and health equity in ways that are responsive, financially fair and make the most efficient use of the available resources. This is supported by six Health Systems Strengthening (HSS) pillars of medicines, vaccines and technologies, human resource, financing, leadership and governance, service delivery and health information systems. A well-functioning health care system ensures equitable access to medicines, vaccines and technologies which results in overall HSS. Tracer essential medicines are supposed to be 100% available at all times to treat the common ailments in a region. Despite the large number of patients that visit public health facilities, the inadequacy of trained pharmaceutical personnel, inefficiencies of the supply chain system and inadequate funding, no study has been carried out to ascertain the availability of tracer essential medicines in these facilities. The objectives of the study were to determine the stocking level of tracer essential medicines, to establish human resource factors affecting availability of tracer essential medicines, to find out the supply chain factors affecting availability of tracer essential medicines and to assess the organizational factors affecting availability of tracer essential medicines. A cross sectional study design with a mixed method approach was used. A questionnaire was used to collect data on the human resource factors and supply chain factors affecting availability of tracer essential medicines. A Focus Group Discussion (FGD) guide was also conducted with seven respondents comprising of six sub County public health nurses and the County pharmacist. The sample population comprised of 17 public health facilities and 30 pharmacy personnel. The response rate was 25 (83.3%). The average stocking level in tier three facilities was 94% while that in tier two facilities was 63.75%. The overall mean percentage stocking level of the 20 tracer essential medicines in all the facilities was 72.65%. Human resource factors that affected availability were unavailability of Standard Operating Procedures (SOPs), inadequate training of pharmacy personnel and pharmacy personnel not aware of tracer medicines. There was a significant relationship between availability of tracer essential medicines and pharmacy personnel awareness of tracer list (r=0.850), pharmacy personnel receiving training in commodity management (r=0.834), availability of SOPs (r=0.817) and designation of pharmacy personnel (r=0.746). The supply chain factors that affected availability of tracer essential medicines were long lead times, unavailability at Kenya Medical Supplies Agency (KEMSA), long ordering and delivery schedules and incorrect quantification. The organizational factors that affected availability were inadequate supportive supervision, inadequate financing and absence of Revolving Drug Funds (RDFs) within the facilities. The study concluded that the stocking level of tracer essential medicines in Nyeri County was below the World Health Organization recommendation of 100%. In addition, human resource factors, supply chain factors and organizational factors affected availability. The researcher recommends that a community pharmacy with subsidized medicines prices be introduced in the facilities; the County should facilitate training of all pharmacy personnel on commodity management, all facilities should have buffer stocks to cover at least two months as they await new stocks and the County should provide supportive supervision to the facilities.
Influence of community health referral practices on antenatal care attendance.
(KeMU, 2016-07) Shibonje, Janet Mukoshi
health system strengthening. In line with the pillar, a Maternal, Newborn and Child Health (MNeCH) Project was initiated by the Ministry of Health and World Vision Kenya in Bamba Division, Kilifi County. The project's goal was to strengthen health systems at the facility and community levels; thus, improve demand for health services, including Antenatal Care (ANC). One of the strategies used by the project to achieve its goal was to strengthen community health referral system. Although studies conducted in various contexts demonstrate the potential of such referral systems in improving ANC indicators, in Kenya, there was a dearth of academic information regarding the subject. This study was initiated to achieve three objective: determine whether providing maternal health education to pregnant women had any influence on ANC attendance in Mirihini (an intervention community in Bamba Division) and Midoina (a control community in the neighboring Bahari Division); determine whether issuing referral advice forms to patients has any influence on ANC attendance in the two communities; as well as establish whether promoting partner support had a significant influence on ANC attendance in the intervention and control communities. This study adopted the static group control design to assess the influence of community health referral practices on ANC attendance in the intervention and control communities. Primary data were sourced from 246 mothers of children aged below 2 years; male and female parents of children aged 2 to 4 years, as well as Community Health Volunteers (CHVs). Quantitative analysis yielded descriptive statistics and cross-tabulations with Chi-square (x2) tests. Qualitative data were transcribed, described and analyzed systematically to reveal themes and patterns. Maternal health education: In Mirihini, there was no significant association between providing maternal health education on the ideal number of ANC visits and women's achievement of optimal ANC attendance (x2 = 1.423, df=1 & a p-value = 0.233); hence, the null hypothesis (H01) was not rejected. In Midoina, a significant relationship between the two aspects was obtained (x2 = 3.109, df = 1 & p-value = 0.078), which led to rejection of the null hypothesis (H01). Referral documentation: In Mirihini, issuing referral documents to pregnant women significantly associated with their achievement of optimal ANC attendance (x2 = 8.308, df =1 & p-value = 0.004). Consequently, the null hypothesis (H02) was rejected. In Midoina, there was no significant association between two aspects (x2 = 0.823, df = 1 & p-value = 0.185); hence, the null hypothesis (H02) was not rejected. Male involvement: In Mirihini, partner counseling significantly associated with women's achievement of optimal ANC attendance (x2 = 14.175, df = 2 & p-value = 0.001), which led to rejection of the null hypothesis (H03). However, in Midoina, there was no significant relationship between the two aspects (x2 = 3.710, df = 2 & p-value = 0.156); thus, the null hypothesis (H03) was not rejected. The intervention and control communities varied in terms of the influence of maternal health education, issuance of referral documentation and partner counseling, on women's achievement of optimal ANC attendance. The study recommends the need for: improved facilitation of CHVs to deliver more information on maternal health; project officers to strengthen supervisory support to CHVs by engaging with MoH to provide reporting materials and ensure consistency of monthly review meetings. Besides, there is need for MoH to involve more male CHVs to influence changes in knowledge and perceptions towards ANC attendance among men.
Factors influencing routine health management information use in public health facilities in Tharaka Nithi County, Kenya.
(KeMU, 2016-07) Mucee, Elizabeth Munda
Routine health management information systems are the foundations of all health systems which strengthen other five pillars hence, strengthening health systems performance. But despite their essential benefits, at the facility level, health workers commonly spend 40 percent or more of their time filling in Health Information Systems forms but may make little or no use of the information for decision making. Information use is determined by multiple factors ranging from technical, organizational and behavioural factors which were drawn from the theoretical framework. The objectives of the study were to determine the technical factors influencing Health Management Information use by health managers and information producers in the public health sector in Tharaka Nithi County; to establish the organizational factors influencing Health Management Information use by health managers and information producers in the public health sector in Tharaka Nithi County and to establish the behavioural factors influencing Health Management Information use by health managers and information producers in the public health sector in Tharaka Nithi County. A descriptive cross-sectional study was conducted in 12 Dispensaries, three Health Centres and one Sub County Hospital in Tharaka Nithi County. Data was collected through researcher administered questionnaires and observation checklist. The respondents were purposely selected from the sampled public health facilities, which included 22 information producers and 53 users in Tharaka Nithi County. The study results identified a set of factors influencing health information use for each of the three categories of factors: technical factors (lack of staff competence at 74 (98.7%), multiple HIS tools at 74 (98.7%) and lack of computers at 74 (93.7%); organizational factors (lack of information use culture promotion at 73 (97.3%) lack of staff training in HIS skills at 69 (92%), and lack of support supervision on information use at 71 (94.7%) and behavioural factors (lack of staff motivation at 73 (97.3 %) and recognition for well done job at 74 (98.7%). The researcher concludes that, for health systems to use health information for evidence-based decisions, technical factors, organizational and behavioural factors must be provided to information producers and users in public health facilities in Tharaka Nithi County. The study recommends: To provide adequate positive technical factors in terms of competent personnel, computers and user-friendly HIS tools to enhance information use; To promote positive organizational factors in terms of promotion of information use culture, support supervision on HIS and support staff training in HIS skills to enhance information use; To initiate and implement motivation and recognition mechanisms in workers' accurate information for use in evidence-based decisions. The researcher suggests further studies to; establish other factors influencing health information use in the public health sector other than those covered by this study; establish interventions to enhance health information use in decision making in public health setting.
Health systems support factors' influence on uptake of immunization services in Kajiado North sub-County.
(KeMU, 2016-07) Toweett, John Kipngetich
Access to health care services is described as the ability by patients to reach and demand health services based on individual needs. Immunization is one of the most effective, safest and efficient public health interventions as it is estimated to save at least 3 million lives from vaccine preventable diseases. Many cultural, religious, or social factors may impede the demand for health care. This study focused on the service delivery pillar. The overall objective was to determine the health system support factors and their influence on access of immunization services in Kajiado North Sub-County. Specific objectives were a) to determine the socio-cultural values that contribute to low access of immunization health services, b) to assess how the packaging of immunization services in the health facilities influence access and c) to establish the relationship between the health promotion activities. This was a cross-sectional study design with a sample size of 280 respondents who were mothers with children below 12 months. Nine health workers were purposively selected for a focused group discussion. Data was analyzed using of ms-Excel, SPSS version 20 and results presented in narratives, tabulations, and graphs. The results revealed that in 2012 and 2013 in Ngong hospital and Fatima health center had a drop in immunization coverage of 128 and 273 children respectively. In addition, the comparative analysis of Kajiado sub-counties on immunization coverage indicated that the sub-county antigen specific coverage reduced as follows: BCG dropped by 4% to 61%, OPV increased by 5% to 75% and measles increased by 3% to 77%. The mean age of respondents was 26.7 years and analysis indicated that level of education negatively influenced immunization access. The distance between households and health facilities ranged from a hundred meters to 20Kms. Approximately 48(17.1%), of mothers visit facilities which are outside the 5 kilometer distance advocated by Kenya health policy. 120(42.8%) suggested that there is need for health promotion activities in the community. The correlation of visits to awareness indicated a p-value of 0.209. 233 (83%) agreed that immunization program is well explained to them when they visit health facilities. The correlation of health education with awareness indicated a p-value of 0.406. The modes of communication clearly portrays that 183(65.4%) of mothers got the information about immunization through continuous health education that is routinely offered in health facilities, whereas 39 (13.9%) mothers got the information through community health promotion. The study recommends a) form outreach teams to trace defaulters of immunization schedules, b) sub-county health office to frequently conduct community health promotion in the villages to discourage cultural believes which contribute to low access to immunization services, and c) package simplified information about the benefits of immunization services shared in health education sessions and during community health promotion.