Effectiveness of the Devolved Primary Health Care Gatekeeper System in Machakos County, Kenya
American Journal of Health Research
Volume 4, Issue 4, July 2016, Pages: 91-99
Received: Jun. 12, 2016;
Accepted: Jun. 22, 2016;
Published: Jun. 30, 2016
Views 4324 Downloads 196
Desire Aime Nshimirimana, Department of Health Systems Management, School of Medicine & Health Sciences, Kenya Methodist University, Nairobi, Kenya
Wanja Mwaura-Tenambergen, Department of Health Systems Management, School of Medicine & Health Sciences, Kenya Methodist University, Nairobi, Kenya
Donald Kokonya, Department of Mental Health, School of Medicine, Masinde Muliro University of Science & Technology, Kakamega, Kenya
Maureen Adoyo, Department of Health Systems Management, School of Medicine & Health Sciences, Kenya Methodist University, Nairobi, Kenya
The low health outcomes and inequities problems in developing countries are due to ineffective gate keeping at the Primary Health Care (PHC) level, non-adherence to policy and dysfunctional health infrastructure. This study was conducted at 100 PHC centres sampled using Taro Yamane formula, in Machakos County, Kenya, from March to May 2015. It involved 8 gender-based focus group discussions (FGDs) with patients and their caretakers. Qualitative and quantitative data were collected from emancipated children and adults aged 15-65 years excluding the disabled due to data integrity issues. The Statistical Package for Social Science (SPSS) version 20.0 and Atlas.ti 7 software were used for data analysis. Correlation was done using the Spearman rho test and significance was set at <0.05. A questionnaire return rate of 83% was achieved of whom 84.3% were nurses (p<0.001) nurses and 15.7% were diploma holders in clinical medicine (clinical officers). The health workers were young (P<0.001) and married (p<0.001). A proportional relationship (rho=0.383, p< .001) existed between the number of out-patients received and cases referred to hospitals. Most gatekeepers were ignorant (p=0.04) about the Policy on the patients’ referral yet they did not officially refer patients (80.7%). Most (63.5%) of the hospitals receiving self-referrals did not ask for referral letters. Policy and referral letters were found to be necessary (p=0.004). The gatekeepers’ non-adherence to policy, lack of laboratory services and shortages of drugs contributed to self-referral by patients, creating a burden on the resources for healthcare, resulting in inefficiency at the PHC level. This study recommends a review of the gatekeeping system at the PHC level, capacity building, quality assurance, redefinition and strengthening of the office of the gatekeepers, regularization of supplies and reinforcement of the patient referral policy, staff motivation and best practices in customer care.
Desire Aime Nshimirimana,
Effectiveness of the Devolved Primary Health Care Gatekeeper System in Machakos County, Kenya, American Journal of Health Research.
Vol. 4, No. 4,
2016, pp. 91-99.
Jamison T. D et al. Global health 2035: a world converging within a generation. The lancet 2013. San Francisco, USA. DOI: http://dx.doi.org/10.1016/S01406736(13)62105-4
WHO. Primary Health Care: Now More Than Ever. World Health Report [internet] 2008. Geneva, Switzerland. Retrieved from http://www.who.int on 2nd December 2014.
Shi L. Impact of Primary Care. A focused review. Hindawi Publishing Corporation. Scientifica 2012. Retrieved from DOI: http://dx.doi.org/10.6064/2012/432892.
Rao M. and Pilot E. The missing link _ the role of primary care in global health. Glob Health Action 2014, 7: 23693 http://dx.doi.org/10.3402/gha.v7.23693
Hsieh C-R. V., Wu C-L. J., Wu N. T and Chiang L. T. Universal Coverage for Primary Health Care Is a Wise Investment. Evidence From 102 Low-and Middle-Income Countries. Asian Journal of Public Health [internet] 2013. Taiwan.
Turin R D. Health Care Utilization in Kenyan Health System: Challenges and Opportunities. Student Pulse [internet] 2010 Vol.2 No 09. Northeastern University in Boston, Massachusetts
Macinko J, Starfield B and Erinosh T. The Impact of Primary Healthcare on Population Health in Low‐ and Middle‐Income Countries. Journal of Ambulatory Care Management 2009 Vol. 32-issue 2-p 150-171. doi: 10.1097/JAC.0b013e3181994221
Starfield B., Shi L. and Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly [internet] 2005. Bethesda, USA. Retrieved from http://www.ncbi.nlm.nih.gov on 2nd December 2014.
Hale L. Integrated Health Care in England: Lessons for Ontario. The Change Foundation. Case Study on Integrated Health Care System. England [internet] 2009. Retrieved from www.changefoundation.ca on 25th February 2016.
Macinko J., Almeida C. and Klingelhoefer de Sa´ P. A rapid assessment methodology for the evaluation of primary care organization and performance in Brazil. Health Policy and Planning 2007; 22: 167–177 doi:10.1093/heapol/czm008
Kousoulis A A, Symvoulakis K E and Lionis C. What Greece can learn from UK primary care experience and empirical research. British Journal of General Practice2012. England. DOI: 10.3399/bjgp12X656928
Wael F S. Reforming Egypt's health system: is it that simple? BMJ 2006; 333:859. doi: http://dx.doi.org/10.1136/bmj.333.7573.859-a
HennessyJ. Federally Qualified Health Centers and Health Reform: Up to the Task? Northwestern Journal of Law and Social Policy [internet] 2013. http://scholarlycommons.law.northwestern.edu/njlsp/vol9/iss1/5
Mash R., Almeida M., Wong W. C. W., Kumar R. and Pressentin B. K. The roles and training of primary care doctors: China, India, Brazil and South Africa. Human Resources for Health2015 13:93. DOI 10.1186/s12960-015-0090-7
Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, et al. What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. Health Service Delivery Research 2015; 3(24). DOI 10.3310/hsdr03240
Willems L. D. Balancing rationalities: gatekeeping in health Med Ethics 2001 27: 25-29 doi: 10.1136/jme.27.1.25 J
Ridde V. Is the Bamako Initiative Still Relevant for West African Health Systems? International Journal of Health Services [internet] 2011. Vol. 41, Number 1/2011. New York, USA. Retrieved from http://baywood.metapress.com on 3rdDecember 2014.
Kegleviü V. M. Effectiveness of Primary Health Care: in Memory of Barbara Starfield. Med Fam Croat2014 Vol 22, No2.
Starfield B. Refocusing the System. The England Journal of Medicine [internet] 2008. Baltimore, USA. Retrieved from http://www.nejm.org on 2nd December 2014.
Luisa M Pettigrew M. L., Maeseneer De J., Anderson P. M., Essuman A., Michael R Kidd R. M. and Haines A. Primary health care and the Sustainable Development Goals. The lancet 2015 vol 386, No. 10009, p 2119-2121, 28 November 2015. DOI: http://dx.doi.org/10.1016/S0140-6736(15)00949-6
Bhatia M. and Rifkin S: A renewed focus on primary health care: revitalize or reframe? BMC Globalization and Health 2010 6:13. doi:10.1186/1744-8603-6-13.
Chatora R. R. and Tumusime P. Primary health care: a review of its implementation in sub-Saharan Africa. Primary Health Care Research and Development2004, pp 296-306 Vol. 5/Issue 04. Doi:http://dx.doi.org/10.1191/1463423604pc220oa
Weel V. C and Maeseneer D. J. Now more than ever. World Health Assembly revisits primary health care. Primary Health Care Research & Development [internet] 2009. Cambridge. Retrieved from http://journals.cambridge.org on 3rd December 2014.
Kruk E. M, Porignon D., Rockers C. P. and Lerberghe V. W. The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives. Social Science & Medicine 2010 vol.70, issue 6, pages 904-911. Doi: 10.1016/j.socscimed.2009.11.025.
Gigli, S, Wright J, Raj F and Agarwal M. Performance Based Incentives to Strengthen Primary Health Care in Haryana State, India. Bethesda, MD: Health Finance &Governance Project, Abt Associates Inc [internet] 2015. www.abtassociates.com
Kahabuka C, Kvåle G, Moland M. K. and Hinderaker G. S. Why caretakers bypass Primary Health Care facilities for child care - a case from rural Tanzania. BMC Health Services Research 2011 11:315. doi:10.1186/1472-6963-11-315
Ministry of Health. The State of the Health Referral System in Kenya: Results from a Baseline Study on the Functionality of the Health Referral System in Eight Counties. USAID and MEASURE Evaluation PIMA2013. Nairobi, Kenya.
Bryan L., Conway M., Keesmaat T., McKenna S. and Richardson B. Strengthening sub-Saharan Africa’s health systems: A practical approach. McKinsey & Company [internet] 2010. Retrieved from http://www.mckinsey.com on 15th April 2016.
Luoma M, Doherty J., Muchiri S., Barasa T., Hofler K, Maniscalco L., Ouma C., Kirika R. and Maundu J. Kenya Health System Assessmen . Bethesda, MD: Health Systems 20/20 project [internet] 2010, Abt Associates Inc
Kruk E M., Hermosilla S., Larson E and Mbaruku M G. Bypassing primary care clinics for childbirth: a cross-sectional study in the Pwani region, United Republic of Tanzania. Bull World Health Organ 2014; 92:246–253. New York, United States of America. doi: http://dx.doi.org/10.2471/BLT.13.126417
Johnson B. and Onwuegbuzie J. A. Mixed Methods Research: A Research Paradigm Whose Time Has Come. Health Policy and Planning 2007; 22:167–177doi:10.1093/heapol/czm008
The 2009 Kenya Population and Housing Census. Counting Our People for the Implementation of Vision 2030. Ministry of State for Planning, National Development and Vision 2030. Kenya National Bureau of Statistics 2010 vol IC. Nairobi, Kenya.
Muga R, Kizito P, Mr. Mbayah M and Gakuruh T. Overview of the Health System in Kenya. Kenya Service Provision Assessment (KSPA 2004) [internet] 2005. Nairobi, Kenya.
Musyoka N. F., Adoyo A. M. and Ongombe O. M. Influence of Job Description on Performance of Health Workers in Public Hospitals: A Case of Mbagathi Hospital, Nairobi City County. Science Journal of Public Health2016. Vol. 4, No. 2 pp. 88-93. doi: 10.11648/j.sjph.20160402.12
Russell J. D, Wakerman J. and Humphreys S. J. What is a reasonable length of employment for health workers in Australian rural and remote primary healthcare services? Australian Health Review2013 37, 256–261. http://dx.doi.org/10.1071/AH12184
Ward T. R. Implementing a gatekeeper system to strengthen primary care in Egypt: Pilot Study. Medical School, Australian National University, Canberra, Australia. Eastern Mediterranean Health Journal [internet] 2010 Vol 16 No 6.
Liu J. J, Bellamy G., Beth Barnet B and Weng S. Bypass of Local Primary Care in Rural Counties: Effect of Patient and Community Characteristics. Annals of family medicine [internet] 2008 vol. 6, no. 2 Baltimore, Maryland.
Joint WHO/GTZ. National Social Health Insurance Strategy: Comments and suggestions of the joint WHO/GTZ mission on social health insurance in Kenya [internet] 2003. Nairobi, Kenya.
Ministry of Health. Kenya Health Sector Referral Implementation Guidelines 1st Edition. Division of Emergency and Disaster Risk Management [internet] 2014. Nairobi, Kenya. http://www.health.go.ke Visited on 24th March 2016.
Ministry of Health. National Referral Policy. Ministry of Health and Social Services. Directorate: Tertiary Health Care and Clinical Support Services 2013. Windhoek, Namibia.