Access, Bottlenecks, Costs, and Equity (ABCE)Understanding the Costs of and Constraints to Health Service Delivery in Kenya

On behalf of the ABCE research teamInstitute for Health Metrics and Evaluation | Action Africa Help-International

January 2015

Overview

• Overview of the ABCE project in Kenya

• Key findingso Facility capacity and service provision

o Non-HIV patient perspectives

o Efficiency and costs of care

o A focus on HIV: service provision and patient characteristics

• Using ABCE work and findings for policymaking

• Conclusions

Overview of the ABCE project in Kenya

Overview of the ABCE project in KenyaABCE study design and implementation

• Collaboration between AAH-I and IHME

• Primary data collection took place April – November 2012.

• Three main data collection mechanisms:o ABCE Facility Survey

o Clinical chart extractions of HIV-positive patients on ART

o Patient Exit Interview Survey

Overview of the ABCE project in KenyaABCE Facility Survey

• Primary data collection from a nationally representative sample of 254 facilities

• Collected data on a full range of indicatorso Inputs, finances, outputs, supply-

side constraints and bottlenecks, indicators for HIV care

• Randomly sampled a full range of facility typeso National and provincial hospitals,

district and sub-district hospitals, maternity homes, health centers, clinics, dispensaries, VCT centers, drug stores or pharmacies, and DHMTs

Overview of the ABCE project in KenyaClinical chart extraction

• Extracted data on HIV-positive patients currently enrolled in ART

• Chart data included patient demographic information, ART initiation characteristics (e.g., CD4 cell count, WHO stage, drug regimen, referral points), and patient outcomes

Overview of the ABCE project in KenyaPatient Exit Interview Survey

• Over 4,200 structured interviews were conducted with patients after they exited facilities from the ABCE sample.

• Interviewees include patients who sought HIV care and those who presented at facilities for non-HIV services.

• Questions included reasons for the facility visit, satisfaction with services, expenses paid associated with the facility visit, and HIV-specific indicators.

Key findings from the ABCE project in KenyaFacility capacity and service provision

Facility capacity and service provisionAvailability of health services in 2012

• Relatively high availability of key services across platforms, especially among public or NGO-owned facilities.o 96% had a formal immunization program.

o 92% offered antenatal care (ANC).

o 91% stocked ACTs for treating malaria.

o 90% had HIV/AIDS care.

o 82% had routine delivery services.

• Other services remained fairly scarce, particularly at lower levels of care and across facility ownershipo e.g., emergency services were available at 59% of private hospitals v.

41% of district or sub-district hospitals; 40% of private centers v. 21% of public health centers

Facility capacity and service provisionGaps in reported and functional capacity for care, 2012

• Many facilities reported providing a given service, but then lacked the full capacity to provide that service (e.g., lacking functional equipment or stocking out of medications).

ServiceFacilities reporting

capacityFacilities with

functional capacity

Antenatal care 89% 12%

General surgery services

58% 13%

Facility capacity and service provisionGaps in reported and functional capacity for ANC

• Sulfadoxine/pyrimethamine (SP) was available across most platforms; however, 45% of health centers and dispensaries did not stock SP.

• Outside of hospitals, few facilities had the capacity to perform important tests for ANC (e.g., blood typing, blood glucose).

• All public health centers in the study lacked ultrasound and did not stock insulin.

• National and provincial hospitals had the smallest discrepancy in reported and functional capacity (100% reported providing ANC, 60% were fully equipped to provide ANC).

• Primary care facilities – health centers, clinics, and dispensaries – had the widest discrepancy (more than 70% reported providing ANC, none were fully equipped).

Facility capacity and service provisionGaps in reported and functional capacity for ANC, 2012

Facility capacity and service provisionAvailability of and deficiencies in physical capital

• Power supplyo All hospitals were connected to the energy grid. o Nearly all primary care facilities also had energy grid connections, with only 11% of

public health centers and 15% of public dispensaries lacking connections.o Across platforms, 36% of facilities with functional electricity also had generator.

• Water and sanitationo Nearly all hospitals had piped water and sewer infrastructure (flush toilets).o 92% of all health facilities had piped water in 2012, a huge gain from a 2010 study

showing that less than 50% of facilities had piped water.o Covered pit latrines remained fairly prevalent across platforms (e.g., 33% of district

and sub-district hospitals had covered pit latrines as their main waste system).

• Transportation and communicationo Outside of national and provincial hospitals, most facilities did not have emergency

transportation.o However, the majority of primary care facilities had access to a phone, which can

facilitate coordination of emergency services.

Facility capacity and service provisionAvailability of and deficiencies in physical capital, 2012

Facility capacity and service provisionAvailability of equipment across platforms

• Individual types of equipmento Across levels of care, the vast majority of facilities had functional

equipment to provide basic medical exams.o Relatively few hospitals had an electrocardiography (ECG) machine.o In the public sector, primary care facilities often lacked equipment to

address many non-communicable diseases (NCDs). 58% of public health centers and public dispensaries lacked the capacity to test

blood sugar (via glucometers) and glucometer test strips.

• Full stocks of medical equipment for levels of care o Applied the WHO Service Availability and Readiness Assessment (SARA)

survey standards for a subset of equipment and their availability.o Health centers often had comparable – or higher – availability of

equipment recommended for their level of care than lower-level hospitals.

Facility capacity and service provisionAvailability of recommended equipment for level of care, 2012

Based on a subset of items from the WHO SARA survey

Facility capacity and service provisionAvailability of pharmaceuticals across platforms

• Based on the 2010 Essential Medicines List (EML), most facilities had at least 50% of the pharmaceuticals recommended for their level of care.

• Stocking of EML pharmaceuticals ranged within platforms, especially public health centers and public dispensaries.

• There was not a clear relationship between EML stocks and the location (urban v. rural) of facilities.

Facility capacity and service provisionAvailability of recommended pharmaceuticals for level of care, 2012

Based on the 2010 EML list

Facility capacity and service provisionCapacity for disease-specific case management

• Assessed the proportion of medical equipment, tests, and pharmaceuticals available to manage a subset of conditions that cause large disease burden in Kenya.

• Identified diseases based on the Global Burden of Disease 2010 study (GBD 2010):o Infectious diseases: lower respiratory infections (LRIs), HIV/AIDS, malaria,

meningitiso Non-communicable diseases (NCDs) and injuries: diabetes, injuries,

ischemic heart disease

• Facilities had the greatest capacity to diagnose and treat LRIs, HIV/AIDS, and malaria, but this capacity generally declined with levels of care, especially in the public sector.

• Facilities were least equipped to manage NCDs, especially among public health centers and public dispensaries.

Facility capacity and service provisionCapacity for disease-specific case management, 2012

Facility capacity and service provisionVaccine storage temperature for immunization services

• Of the facilities that routinely stored vaccines, 17% had refrigerators operating outside of the optimal range (2°C to 8°C).

• A greater proportion of facilities had storage temperatures above the optimal range than below the recommended range.

• Private hospitals (33%) and private health centers (31%) had the greatest proportion of storage temperatures below 2°C or above 8°C.

• Poor access to functional electricity did not seem directly related to improper storage temperatures.

Facility capacity for service provisionVaccine storage temperature for immunization services, 2012

Facility capacity and service provisionCapacity to test for and treat malaria

• 91% of all facilities, including pharmacies, stocked artemisinin-combination therapies (ACTs) at the time of facility visit.

• All national and provincial hospitals had the concurrent availability of ACTs and malaria testing; 95% of public health centers and 93% of private centers had both ACTs and testing capacity (microscope or rapid diagnostic tests [RDTs]).

• Fewer dispensaries, clinics, and pharmacies stocked both ACTs and RDTs, with the lack of testing capacity generally being the main limitation.

• Demonstrates a successful uptake of Kenya’s policy for parasitological confirmation of malaria at higher levels of care.• Private and NGO-owned facilities generally showed a lower availability of

malaria testing than their public equivalents.

Facility capacity for service provisionCapacity to test for and treat malaria, 2012

Facility capacity and service provisionHuman resources for health

• Nurses accounted for the largest proportion of staff personnel in public facilities. Non-medical staff generally composed the majority of personnel at private facilities.

• Two national hospitals, five district hospitals, and 15 public health centers reached the national staffing targets outlined by the KHSSP, 2012-2018.

• Urban facilities generally had many more medical personnel than rural facilities at the same level of care; this was particularly pronounced among district and sub-district hospitals.

Facility capacity and service provisionHuman resources for health: personnel composition, 2011

Facility capacity and service provisionHuman resources for health: district and sub-district hospitals, 2011

Facility capacity and service provisionHuman resources for health: public health centers, 2011

Facility capacity and service provisionOutputs, 2007-2011

• Outpatient visits remained relatively stable over time across facilities.o Private hospitals and public dispensaries recorded some increases in

outpatient visits between 2010 and 2011.

• Inpatient visits were fairly consistent between 2007 and 2011.o National, provincial, and private hospitals recorded gradual increases in

inpatient visits during this time.

• ART visits rapidly rose at a subset of platforms from 2007 to 2011.o Across facilities, there was a 22% increase in average number of ART visits.

o This increase was largely driven by public health centers, which averaged a 109% increase in ART visits between 2007 and 2011.

o ART visits remained more stable among hospitals.

Facility capacity and service provisionOutputs: average outpatient visits, by platform, 2007-2011

Facility capacity and service provisionOutputs: average inpatient visits, by platform, 2007-2011

Facility capacity and service provisionOutputs: average ART visits, by platform, 2007-2011

Key findings from the ABCE project in KenyaNon-HIV patient perspectives

Non-HIV patient perspectivesPatient reports of expenses associated with facility visit

• As part of the Patient Exit Interview Survey, patients who did not seek HIV services reported the types of expenses they had in association with the facility visit.

• Based on the ABCE sample, most patients reported some kind of medical fee associated with their facility visit, but fee amounts varied across and within facility types.

Non-HIV patient perspectivesPatient reports of expenses associated with facility visit, 2012

Non-HIV patient perspectivesLevels of patient medical expenses

• In 2004, Kenya enacted the “10/20” policy to reduce user fees at public dispensaries and public health centers.

• Of patients seeking care at public health centers, 75% spent 20 Kshs or less in user or registration fees.

• At public dispensaries, 61% of patients paid no more than 10 Kshsin user or registration fees.

Non-HIV patient perspectivesLevels of patient medical expenses, by facility, 2012

Non-HIV patient perspectives Patient wait times at facilities

• Across facilities, 78% patients reported less than an hour waiting for care.

• At national and provincial hospitals, 23% of patients spent more than two hours waiting for care. At maternity homes, 90% of patients received care within 30 minutes.

• In general, a greater proportion of patients received care within an hour at private facilities than at their public equivalents.

Non-HIV patient perspectives Patient reports of wait times at facilities, by platform, 2012

Non-HIV patient perspectives Patient ratings of facilities

• Overall, patients gave high ratings for care received across platforms.

• Patients rated staff interactions highly, especially for medical provider respectfulness.

• For facility characteristics, patients generally gave higher ratings for cleanliness and privacy, but lower ratings for spaciousness and wait time (especially at public facilities).

Non-HIV patient perspectives Patient overall ratings of facilities, by platform, 2012

Non-HIV patient perspectives Average patient ratings of facility indicators, by platform, 2012

Key findings from the ABCE project in KenyaEfficiency and costs of care

Efficiency and costs of careEstimating efficiency: Data Envelopment Analysis (DEA)

• DEA: quantifies the relationship between a facility’s resources (medical staff, beds) and its production of services (outpatient visits, inpatient bed-days, births, and ART visits) relative to comparably sized facilities in the ABCE sample.

• Efficiency score: a value between 0% and 100%, reflecting the alignment of facility resources to service production.o 100% = maximum use of facility resources for output production

• Outpatient equivalent visits (OEV): weighting different outputs in a standardized way to allow for direct comparisons across facilities.o Average across facilities:

Inpatient bed-day = 3.8 outpatient visits Birth = 9.4 outpatient visits ART visit = 1.7 outpatient visits

Efficiency and costs of careAverage production of outputs across facilities

• Across platforms, facilities averaged a total of seven outpatient equivalent visits per medical staff per day, ranging from 4.7 visits at private hospitals to 13.2 visits at public dispensaries.

• Outpatient visits accounted for the largest proportion of patient visits experienced per medical staff per day at primary care facilities, district, and sub-district hospitals.

• Inpatient bed-days accounted for the largest proportion of patient visits produced per medical staff per day at national and provincial hospitals.

• Private health centers the largest volume of ART visits per medical staff per day (0.8 as measured in OEV).

Efficiency and costs of careAverage production of outputs across facilities, 2011

Note: All visits are in outpatient equivalent visits, with an average of one inpatient bed-day equaling 3.8 outpatient visits; one birth equaling 9.4 outpatient visits; and one ART visit equaling 1.7 outpatient visits.

Efficiency and costs of careEfficiency scores varied across and within platforms

• Across all facilities, the average efficiency score was 41%.

• More than 60% facilities had an efficiency score at or less than 50%.

• Average efficiency scores generally declined in parallel with decreasing levels of care among public facilities.

• Public facilities averaged higher efficiency scores than private facilities at the same level of care.

• Tremendous range in efficiency scores within platforms:o At least one facility had an efficiency score of 100% for nearly all platforms.o Multiple facilities had efficiency scores close to 0% for most facility types.

• No consistent relationship between urbanicity and efficiency scores:o Urban hospitals generally had higher efficiency scores than rural hospitals.o Rural dispensaries and clinics generally had higher efficiency scores than urban

dispensaries and clinics.

Efficiency and costs of careEfficiency scores across platforms, 2007-2011

Efficiency and costs of careEstimated potential for expanded service production

• We estimated that facilities had substantial potential for increasing output production, especially among lower levels of care.

• An average of 12 additional visits, measured in OEV, could be added across facilities, based on observed resources.

• This potential for expanded service production does not reflect the quality of services delivered; it shows the alignment of facility resources and output production.

Efficiency and costs of careEstimated potential for expanded service production, 2011

Efficiency and costs of careCross-country comparison of efficiency

• Other countries involved in the ABCE project showed more potential for expanded service provision, given observed resources, than Kenya.

Efficiency and costs of careEstimating costs of care

• Using information produced through DEA, output-specific spending by facilities was divided by outputs produced by each facility.

• All cost data were adjusted for inflation and reported in 2011 Kenyan shillings (Kshs). o All US dollar estimates were based on the 2011 exchange rate of 83 Kshs

per $1.

Efficiency and costs of careAverage facility cost per visit, across outputs and by platform

• Facility costs per patient visit varied across platforms and by output type.

• The average facility cost per outpatient visit was generally the least expensive to produce, and births were the most expensive.

• National and provincial hospitals generally spent the most per patient visit produced, whereas private health centers generally produced patient visits at the lowest facility cost per output.

Efficiency and costs of careAverage facility cost per visit, across outputs and by platform

Efficiency and costs of careCross-country comparison of output costs

• Kenyan facilities averaged the least expensive production cost per outpatient visit and ART visit (excluding the cost of ARVs).

Key findings from the ABCE project in KenyaA focus on HIV: service provision and patient characteristics

HIV service provision and patient characteristicsART regimen at initiation, 2008-2012

• From 2008 to 2012, there was a rapid transition away from d4T-based ART regimens toward those with a TDF backbone for ART initiates.o In 2008, 73% of ART patients initiated on d4T. In 2012, 8% did.

o In 2008, 3% of ART patients initiated on TDF. In 2012, 45% did.

• TDF prescription rates varied across facilities, from 0% to 97% in 2011 and 2012. o Public health centers generally had slightly lower proportion of ART

patients initiating on TDF-based regimens than hospitals in 2011 and 2012.

HIV service provision and patient characteristicsART regimen at initiation, 2008-2012

HIV service provision and patient characteristicsART regimen at initiation, by facility, 2011-2012

HIV service provision and patient characteristicsPatient clinical characteristics at ART initiation: WHO staging

• There was a steady shift toward ART initiation at earlier stages of disease progression between 2008 and 2012.

• In 2008, 40% of patients initiated at WHO stage 1 or 2. In 2012, 68% began treatment at the same stages.

• There was substantial heterogeneity in ART initiation by WHO stage across facilities in 2011 and 2012.o In general, public health centers saw a greater proportion of ART

patients starting therapy at WHO stage 1 or 2 than hospitals.

HIV service provision and patient characteristicsWHO stage at initiation, 2008-2012

HIV service provision and patient characteristicsWHO stage at initiation, by facility, 2011-2012

HIV service provision and patient characteristicsPatient clinical characteristics at ART initiation: CD4 cell count

• A greater proportion of ART patients began therapy at higher CD4 cell counts in 2012 than in 2008.o In 2008, 40% of patients initiated at a CD4 cell count of 200 cells/mm3

or higher. In 2012, 58% of patients initiated at this level of CD4.

• Median CD4 cell count increased 55%, from 155 cells/mm3 in 2008 to 241 cells/mm3 in 2012.

• A substantial portion of ART patients still began therapy once they were symptomatic.o About 20% of patients initiated ART with a CD4 cell count less than 50

cells/mm3 from 2008 to 2012.

HIV service provision and patient characteristicsCD4 cell count at initiation, 2008-2012

HIV service provision and patient characteristicsFacility availability of patient clinical information

• Testing rates have remained stable over time, indicating that recordkeeping has increased in parallel with rising ART patient volumes.

• In 2012, a portion of ART initiates still did not receive key tests.o 27% lacked a CD4 cell count.

o 5% were not assigned a WHO stage.

o 1% did not have a weight measurement.

o 73% did not have a height measurement.

• Follow-up measures of CD4 cell counts were relatively infrequent, especially in comparison with Kenyan guidelines.

HIV service provision and patient characteristicsFacility availability of patient clinical information

HIV service provision and patient characteristicsFacility 12-month retention rates for ART patients

• After 12 months of treatment, 70% of ART patients in the ABCE sample were retained in care.

• Patients who initiated ART at WHO stage 4 showed lower program retention rates (42%) than patients who initiated ART at WHO stage 1 or 2 (78%).

• Retention rates varied by facility, ranging from 18% to 89%.

HIV service provision and patient characteristicsFacility 12-month retention rates for ART patients, 2011

HIV service provision and patient characteristicsART patient reports of expenses associated with visit, 2012

• As part of the Patient Exit Interview Survey, patients who sought HIV services reported the types of expenses they had in association with their facility visits.

• Kenyan national policy stipulated that ART care should be free at public hospitals and public health centers in 2006.

• Based on the ABCE sample, very few ART patients (2%) reported any medical expenses associated with visits to public facilities.

• More than 50% of ART patients experienced some kind of transportation expense, especially national and provincial hospitals (70%).

HIV service provision and patient characteristicsART patient reports of expenses associated with visit, 2012

HIV service provision and patient characteristicsART patient reports of wait times at facilities

• Overall, ART patients reported relatively long wait times at facilities.

• At some facility types, ART patients generally spent more time waiting than non-HIV patients at similar facilities.o District and sub-district hospitals

Nearly 20% of ART patients waited more than two hours. 10% of non-HIV patients waited more than two hours.

• At other facility types, more ART patients reported having shorterwait times than non-HIV patients.o Private facilities

About 90% of ART patients received care within one hour; 0% waited more than 2 hours. About 84% of non-HIV patients received care within one hour; about 4% waited more than

2 hours.

HIV service provision and patient characteristicsART wait times at facilities, by platform, 2012

HIV service provision and patient characteristicsART patient ratings of facilities

• Overall, ART patients gave high ratings for care received across platforms.o Over 60% of ART patients gave at least a rating of 8 out of a possible 10.

• ART patients generally gave higher ratings, across facility indicators, than non-HIV patients.

• Like non-HIV patients, ART patients rated staff interactions highly, especially for medical provider respectfulness.

• ART patients gave high ratings of facility cleanliness and privacy, but rated wait time very poorly – particularly at national and provincial hospitals.

HIV service provision and patient characteristicsART patient overall ratings of facilities, by platform, 2012

HIV service provision and patient characteristicsAverage ART patient ratings of facility indicators, by platform, 2012

HIV service provision and patient characteristicsEfficiency scores for facilities providing ART

• Across facilities with ART, the average efficiency score was 51%.

• ART facilities typically had higher levels of efficiency, compared to all facilities in the ABCE sample.

• There was potential to expand ART patient volumes, especially among private facilities.

HIV service provision and patient characteristicsEfficiency scores for facilities providing ART

HIV service provision and patient characteristicsEstimated potential for increased ART visits given resources

• We estimated that many facilities had potential for increasing annual ART visits.

• Given observed facility resources, we estimated that an average of 3,499 additional ART visits could be added, per facility, each year.

• This gain represents a 69% increase in ART visits from the average annual ART visits observed in 2011 (5,070 ART visits).

HIV service provision and patient characteristicsEstimated potential for increased ART visits given resources

HIV service provision and patient characteristicsCross-country comparison of ART efficiency

Kenya showed potential for expanded ART provision, given observed resources, but at a lesser magnitude than Zambia.

HIV service provision and patient characteristicsProjected facility ART costs: analytical approach

• Four streams of data were used to project ART costs1. Average facility cost per ART visit, excluding ARVs, based on the ABCE

sample2. Average number of annual visits observed for new and established ART

patients in 2011, as extracted from clinical charts3. The ARV regimens of ART patients in 2011 extracted from clinical charts4. The ceiling ARV prices for 2011 published by the Clinton Health Access

Initiative (CHAI)

• Analytical steps for projecting ART costs1. Visit costs: multiplied average facility cost per ART visit, excluding ARVs, by

the average number of annual visits observed for new and established ART patients in 2011.

2. Total costs: using the relative proportion of TDF-, d4T-, and AZT-based regimens observed for patients, applied the ceiling price for each ARV and added projected ARV costs to estimated visit costs.

HIV service provision and patient characteristicsProjected facility ART costs, 2011

• ARVs accounted for a large portion of projected annual facility costs for ART, but slightly varied across patient types and platforms.o New patients

ARVs accounted for 61% of total projected ART costs to district and sub-district hospitals.

ARVs accounted for 74% of total projected ART costs at private facilities.

o Established patients ARVs accounted for 65% of total projected ART costs to district and sub-district

hospitals. ARVs accounted for 76% of total projected ART costs at private facilities.

• Facility costs for ARVs may be viewed as more stable over time, whereas visit costs associated with ART services are likely to be lower for established patients.o Substantial implications for longer-term ART care and funding sources

HIV service provision and patient characteristicsProjected facility costs for ART, 2011

HIV service provision and patient characteristicsCross-country comparison of ART costs

• Kenyan facilities had comparable ART costs to those in Uganda, but were much lower than Zambia.

• ARVs accounted for 69% of annual facility costs in Kenya, which was less than Uganda (72%) and more than Zambia (60%).

Using ABCE work and findings for policymaking

Using ABCE for policymakingIdentifying health system progress and challenges

• Provides policymakers with the evidence to pinpoint areas of success and for improvement as linked to national goals and priorities

• Enables direct comparisons across facility types and ownership, allowing policymakers to contrast facility capacity in the public sector with that of the private sector

• Supports the timely use of data to inform policy dialogue

Using ABCE for policymakingABCE Kenya policy report

http://www.healthdata.org/dcpn/kenya

Conclusions

ConclusionsFacility capacity for service provision

• High availability of a subset of services reflects service availability has expanded for a subset of the Kenya Essential Package for Health (KEPH).o Immunization, HIV/AIDS care, ANC, concurrent availability of malaria diagnostics and

treatment.

• Substantial gaps in reported capacity and full capacity to provide services found across all levels of care. o This was particularly pronounced among primary care facilities and for the

management of NCDs.

• Nearly all facilities had functional electricity and piped water, but gaps remained at different levels of care in the public sector.o This gap was further illustrated by variable access to improved sanitation.

• Facilities had a moderately high availability of recommended equipment and pharmaceuticals, but stocks varied greatly within facility types.

• Over 60% of facility employees were skilled medical staff. Urban facilities generally had higher levels of skilled medical personnel than rural facilities.

ConclusionsFacility production of health services

• Average patient volumes gradually increased across platforms, whereas ART visits rapidly grew at private hospitals.

• Shortages in human resources and facility overcrowding have been viewed as widespread; in the ABCE sample, most facilities averaged fewer than seven visits per medical staff per day.

• Given observed facility resources, service production could be potentially increased by an additional 12 outpatient equivalent visits, on average, per facility.

• Annual ART visits could potentially increase as well, but by a more moderate magnitude (a 69% gain).

ConclusionsPatient perspectives

• Most non-HIV patients reported medical expenses associated with their facility visit.o The majority of non-HIV patients had medical expenses in alignment with Kenya’s

10/20 policy.o However, a number of public health centers and dispensaries had patients reporting

user and registration fees exceeding the 10/20 policy payment structure in 2012.

• In general, a large portion of patients spent more time waiting at facilities to receive care than the time they spent traveling to the facility.o Given average staffing observed across facilities and patients seen per medical staff

per day, it is unlikely that inadequate human resources are the main driver of these long wait times.

• Patients gave high ratings of facilities, especially ART patients and for private facilities.o Staff interactions were regularly rated higher than facility characteristics, though

facility cleanliness received high ratings as well.o Patients gave fairly low ratings of wait time.

ConclusionsFacility costs of care

• Average facility cost per patient visit differed substantially across platforms and types of visits.

• In comparison with a subset of other countries in the ABCE sample, average facility costs in Kenya were low per ART visit and higher for outpatient visits and inpatient bed-days.

• On average, ARVs accounted for a large proportion of ART facility costs, but how much varied based on patient status (new or established).o Projected ART facility costs, including ARVs, were generally lower in Kenya

in comparison with Uganda and Zambia.o ARVs contributed to a larger portion of overall annual costs in Kenya (69%)

than in Zambia (60%) but less than those for Uganda (72%).

ConclusionsFacility-based provision of ART services

• A rapid shift away from d4T-based ART regimens and toward TDF occurred throughout Kenya – a significant success.

• Steady progress took place for initiating ART patients at earlier stages of disease, for both WHO staging and CD4 cell counts.• However, a portion of patients still began treatment after becoming

symptomatic in 2012.

• Gradual improvements were made in collecting ART patient clinical data, but too few did not receive key measures and tests at initiation and during follow-up visits.o Greater investment in ART patient recordkeeping and data collection

ought to be considered.

ConclusionsPriority considerations for future work

• Updated analyses across indicators to assess progress and to identify areas that may require more investment.

• Targeting a broader set of facilities to capture a clearer picture of levels and trends in facility performance.

• Linking estimates of efficiency to quality of the services produced at facilities, as well as other factors. o e.g., expediency with which patients receive care, demand for increased services

• Updated analyses for ART patient characteristics at initiation, to determine more recent uptake of new eligibility guidelines.

• Generating estimates of cost-effectiveness based on facility delivery of services and costs of production, and linking to ongoing work on estimating trends in health outcomes and disease burden.

Thank you

http://www.healthdata.org/dcpn/kenya