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Mulupi, Stephen (2022) Chronic respiratory diseases in Meru County, Kenya: how do public health systems respond and what are the opportunities for health system strengthening?, Thesis (Doctoral), Liverpool School of Tropical Medicine.
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Abstract
Introduction
Chronic respiratory diseases (CRD) are associated with premature mortality, poor health, impaired quality of life and adverse socioeconomic implications. Health systems need to be responsive to chronic respiratory diseases and other non-communicable diseases but many health systems in low- and middle-income countries are not designed or resourced to deliver chronic care effectively. This thesis is set in Kenya, a lower-middle income country in Eastern Africa. Kenya’s health system was devolved in 2013 leading to 47 subnational governments (counties) managing most healthcare services, from primary healthcare to secondary referral hospitals. Over the last decade, Kenya has seen an increased focus on community health programmes and key health financing reforms such as the National Hospital Insurance Fund to achieve universal health coverage. The diagnosis and management of chronic diseases, however, remains neglected.
The burden of chronic respiratory diseases has been rising steeply over the last two decades, but Kenyan respiratory services continue to prioritise tuberculosis (TB) diagnosis and care. There is scarce evidence on the readiness of public healthcare systems to provide appropriate care for the wider group of people seeking care with symptoms of CRD who are not diagnosed with TB in Kenya. The main non-TB cause of CRD symptoms in Kenyan communities is asthma, which is associated with significant mortality and morbidity among both children and adults when untreated.
The aim of this study was to investigate the readiness of the devolved Kenyan public healthcare system to respond to people with symptoms of CRD and to explore the perceptions and impacts of living with CRD symptoms in Kenyan communities. The study used asthma diagnosis and care as a lens through which to identify opportunities to strengthen the response across the whole continuum of care for CRD.
Objectives
1. Health system readiness: To assess the readiness of the Meru County public healthcare system to respond to people with symptoms of CRD and identify opportunities for improvement of asthma diagnosis and care among adults and children in Meru County.
2. Community experiences and perceptions: To explore community perceptions and health-seeking behaviours related to symptoms of CRD and investigate the role of the community health system in supporting referral to healthcare services and the subsequent management of people with asthma.
3. Socioeconomic impact: To estimate the socioeconomic impact, including catastrophic costs, of illness and care-seeking among adults with symptoms of CRD and assess the coverage and use of Kenya’s social protection scheme the “National Hospital Insurance Fund” (NHIF) to pay for related healthcare facility visits.
Methods
The study was conducted in Meru County Kenya. Five public healthcare facilities representing primary healthcare (n=2), primary referral hospitals (n=2) and a secondary teaching and referral hospital (n=1); and community sites (n=8) were included. Different methods were used to address the three key objectives with cross cutting issues such as governance, financing and policy explored across multiple methods and levels.
Health system readiness: A readiness assessment at the five facilities examined availability of resources (infrastructure, equipment, drugs including inhalers, trained healthcare workers, policy guidelines), coordination of health care services delivery, and patients’ responses to diagnosis, treatment, and management plans. Data were collected using a standardised questionnaire administered with healthcare workers and triangulated with findings from in-depth interviews with healthcare workers (n=44) and key informant interviews with decision-makers in the Meru County Department of Health (n=13).
Community experiences and perceptions: Community in-depth interviews and focus group discussions (FGDs) documented and explored the experiences of community health volunteers (n=81) in supporting referrals and linkage of community members to the formal health system; and community members’ (n=32) experiences of healthcare delivery and access to primary healthcare facilities and secondary referral hospitals.
Socioeconomic impact: Exit interviews with adults seeking care for CRD symptoms (n=296) estimated lost income, and direct medical and non-medical costs of healthcare facility visits, membership of the NHIF and reasons for not enrolling; coping mechanisms for paying for healthcare services; and exposure to catastrophic healthcare expenditure of care-seeking, defined as total health-related costs >40% of monthly non-food/rent/leisure expenditure of the participants’ households (also known as a household’s “capacity to pay”).
Findings
Health system readiness: key challenges identified included lack of healthcare workers’ capacity, inadequate equipment, and poor coordination of systems for diagnosis and treatment of chronic respiratory diseases. These challenges indicate the health system is inadequately prepared to deal with chronic respiratory diseases. The quality and continuity of drug supply, including inhalers, was adequate.
However, the stigma related to the chronic respiratory diseases like asthma impacted on treatment plans and management, including prescription and demonstration of inhaler use. There were multiple challenges in health systems’ governance, which if left uncorrected could significantly undermine chronic respiratory disease care and wider systemic reforms. These included: delays in payment of healthcare workers’ salaries and lack of promotions, both of which led to frequent strikes; suboptimal financial accountability; and weak coordination of funds disbursement between the national and county governments.
Community experiences and perceptions of asthma care: the linkages between the community health system and healthcare facilities were weak. There was poor communication and working relations between community health volunteers and formal healthcare workers around chronic respiratory disease and asthma; inadequate material, financial and training support for community health volunteers; and poor coordination of service delivery. Conditions of poverty of participants’ households made referral uptake difficult. Stigma related to asthma was widely reported as an important barrier to both health-seeking behaviour and chronic asthma management. These barriers were perceived to translate into missed opportunities and suboptimal involvement of community health volunteers in asthma management.
Socioeconomic impact associated with having symptoms of chronic respiratory disease: More than half of participants (142/296; 52%) experienced catastrophic healthcare expenditure related to seeking care for chronic respiratory disease symptoms. Factors independently associated with experiencing catastrophic healthcare expenditure included being female (adjusted odds ratio, aOR, 2.2, 95% CI 1.2-4.2, p=0.011); being the primary income earner of the household (aOR 2.0, 95% CI 1.0-3.9, p=0.044); belonging to the poorest tercile of participant households (aOR 2.4, 95% CI 1.2-4.8, p=0.017), and seeking care from a subcounty hospital (aOR 2.5, 95% CI 1.3-5.1, p= 0.008). The principal coping strategies were using savings (173/296; 58%) and borrowing money (91/296; 31%). Of the more than two thirds of participants (212/296; 72%) who were not covered by NHIF, the most common reported barriers to NHIF enrolment were unaffordability of insurance premiums (92/212; 43%), unawareness of eligibility (56/212; 26%) and inadequate information (44/212; 21%). Of those covered by NHIF, 73/84 (87%) did not use NHIF to pay for their chronic respiratory disease care due to not being asked about NHIF (30/73; 41%), not being up to date with NHIF premiums (22/73; 30%), or the healthcare facility not taking NHIF cards (16/73; 22%).
Discussion
This is the first reported evidence from Kenya showing inadequate health system responses to chronic respiratory diseases, high levels of asthma-related stigma and a high prevalence of catastrophic costs experienced by people seeking care for CRD symptoms, including asthma. These three areas (health system responses, community stigma and catastrophic costs) interact in a vicious cycle that spans from community to health facilities. Being female, poorer, primary income earner, and seeking care at subcounty hospitals were independently associated with experiencing catastrophic costs. This indicates gender and socioeconomic inequalities in healthcare access for people seeking care with CRD symptoms and highlights the potential role for social protection including NHIF to reduce income loss and review of care-seeking, diagnostic, and referral pathways to reduce out-of-pocket costs, especially at subcounty hospital level. There are significant gaps in terms of equipment and training on chronic respiratory diseases in health facilities. Our findings indicate however that interventions such as social protection and health care worker training will not be effective unless communities and staff training are also addressing stigma.
Conclusions and recommendations
The Kenyan health system is inadequately prepared to provide adequate care for people with symptoms consistent with non-communicable CRD such as asthma. Priority, targeted interventions to achieve health system strengthening include empowering community stakeholders through stigma reduction programmes and enhanced social protection; enhancing diagnostic capacities through training healthcare workers to do peak flow diaries and spirometry testing and supply of peak expiratory flow meters; and through advocating for adequate remuneration of the community health volunteers, strengthening community health systems’ linkage to healthcare facilities and county governance systems.
| Item Type: | Thesis (Doctoral) | ||||
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| Subjects: | WA Public Health > WA 20.5 Research (General) WA Public Health > Health Administration and Organization > WA 540 National and state health administration WA Public Health > Health Administration and Organization > WA 546 Local Health Administration. Community Health Services WF Respiratory System > WF 20 Research (General) |
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| Faculty: Department: | Clinical Sciences & International Health > International Public Health Department | ||||
| Depositing User: | Lynn Roberts-Maloney | ||||
| Date Deposited: | 03 Oct 2023 13:33 | ||||
| Last Modified: | 03 Jan 2024 04:12 | ||||
| URI: | https://archive.lstmed.ac.uk/id/eprint/23259 |
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