The study investigated the current state of readiness of Kenyan health facilities to deliver NCD services. Three aspects of the NCD-specific services were evaluated; service availability, service readiness, and the assessment of factors associated with the readiness of health facilities to provide NCD services based on a 70% service-specific readiness score cut-off. Study findings highlighted both strengths and weaknesses in the existing health care system, as well as areas for improvement in regard to the management of NCDs. Firstly, the availability of diabetes, CVD, and CRD services was relatively good, with over two-thirds of health facilities reporting that these services were available. Diagnosis and/or management services for CRD were widely available at all levels of care, type of facilities, and location settings. In contrast, only a quarter of the facilities surveyed provided cervical cancer screening.
Secondly, readiness to offer specific services for NCDs varied by disease, and important gaps were identified in the availability of tracer items at all levels, types of care, urban versus rural facilities, and between the regions in Kenya. Diabetes was identified as the condition the majority of facilities were reasonably prepared to manage. Nonetheless, readiness was primarily influenced by the high availability of equipment tracer items rather than other service domain indicators. Similarly, although the overall CVD service readiness scores were relatively high, there were notable shortcomings in the availability of trained personnel and national guidelines on the management of this condition. Furthermore, the study revealed that even though CRD services were reported to be the most available in the facilities, the overall readiness to offer this service was generally poor and below the WHO recommended voluntary global target levels . Nevertheless, facilities offering cervical cancer services were found to have high readiness scores for this condition because they had the necessary domain tracer items to provide the ser. However, these results may not be a true reflection of the levels of readiness to manage this condition due to the small number of facilities assessed. As such, these results were can only be viewed as descriptive.
Thirdly, the results of the logistic regression modeling revealed that private facilities were always more likely to be ready to provide NCD-specific services than public facilities. Similarly, hospitals (that is at higher-level facilities) were found to be significantly associated with readiness to provide services for NCDs management as compared to primary health facilities, at the lowest levels of care. Furthermore, urban-rural differences in service-specific readiness were noted, particularly for diabetes services management, with urban facilities more likely to be “ready” to offer services for this condition than those located in rural areas. The modeling also revealed significant disparities in service readiness between regions. This pattern was observed for all the diseases assessed.
Our findings highlighting a lack of overall access to some essential specific NCD services are similar to reports from other previous studies, which concluded that NCD interventions were generally lacking in the country, particularly in the poorer regions and in the public sector [17, 25]. Nonetheless, there were also some positives to appreciate. The current study, for instance, found that the availability of equipment for NCD interventions was generally good, and this should be viewed as a positive step forward. In part, this could attributed to the many policies and initiatives implemented by the Ministry of Health Kenya to reduce the burden of NCDs, including the Kenya National Strategy for the Prevention and Control of NCDs 2015–2020 .
Consistent with our current findings, previous studies have also shown disparities in the availability of health care resources for the prevention and control of NCDs between levels of care, types of facilities, and their rural-urban locations [1, 24, 27]. These current findings are important in that they further highlight that where NCDs health services are needed most by the populations (that is, at primary care, public and rural facilities), they are not always readily available in these settings. To further reiterate the message, it is important to identify and highlight these gaps in services because public and rural facilities are the most accessible units of care for most populations in LIMCs. Thus, there is need for more resources need to be channelled towards these areas to close the gap and hence establish properly functioning health systems that are responsive to the health care needs for NCDs.
Closely related to the above findings, another cause for concern was the substantial lack of essential medicines and commodities for NCDs, particularly among the public and rural facilities consistently highlighted in our study and also reported in other previous studies [14, 28, 29]. Moreover, this was often accompanied by shortages of trained health professionals at these facilities. With limited access to medicines, the patients’ best option may be to obtain them at higher-priced private facilities and private drug outlets . This will more likely affect poorer members of the population such as those in rural areas, who are less likely to have the resource to travel long distances to access health care . To further highlight this plight, a recent qualitative study on the perception of Kenyan adults on access to medicines for NCDs reported that when medications were not readily available, patients were more likely to only take a portion of the prescribed dose or even go for days without taking them at all . This could potentially lead to disease progression and can also affect medication compliance when the treatment is considered taken yet the dosage is not adequate . It is also important to emphasize that availability of medicines and health worker training domains complement each other, for instance, even if trained human resources were available to provide patients with services, the lack of essential medicines and commodities will prevent the health professional to deliver the appropriate care, and vice versa . There is therefore a compelling need to address medicines and trained staff shortages concurrently, as this could help improve management, consequently resulting in improved drugs availability and supply.
These disparities in service-specific readiness have also been reported within countries or sub-regions of countries in SSA . The widespread lack of essential resources has hindered progress in the management and prevention of NCDs in the region [32, 33]. For example, a study reviewing the progress of all 47 countries in the WHO African Regions revealed that none of the countries met all the recommended indicators for service-specific readiness . Global trends have also highlighted similar gaps. A recent report by the WHO monitoring non-communicable disease progress in 2020 using data from 194 countries highlighted that the majority of countries, particularly LMICs, had not met the set global targets, further reiterating the urgent global need to advance work on NCDs prevention and control .
The findings of this study offer a reminder that has important implications for healthcare policy in the country. Furthermore, these current study implications also extend to other LMICs, as previously published evidence has highlighted the need for health systems strengthening and re-organization to ensure effective NCD prevention and control . Despite CVD being the most common of the NCDs , facilities were less prepared to manage them compared to diabetes. There is therefore a need for services to be prioritized according to disease burden. The gaps identified for the different diseases at different types and levels of care, as well as the notably regional and urban-rural disparities, coupled with sub-optimal availability of essential medicines and commodities, emphasize the need for a “complete package” approach to expanding the capacity of health facilities to deliver effective NCD interventions. Firstly, efforts need to be implemented at primary care, as well as in public and rural facilities collectively, to ensure universal health coverage, since these facilities are more accessible to the majority of the population. This is relevant particularly when considering that patients with undiagnosed conditions who live in less prepared areas, and who may be asymptomatic for years are more likely to encounter inadequate screening, treatment, and referral to care, resulting in long-term negative consequences such as chronic morbidity. Consequently, this could contribute to the rising disease burden and poor possible health outcomes from NCD interventions. These gaps could be addressed by re-prioritizing funds to provide these facilities with adequate diagnostic capacity, laboratory tests or procedures, and more importantly, by focusing on increasing accessibility to essential medicines at these facilities.
The variation of health facilities’ readiness between regions and urban-rural disparities should be also addressed. Kenya’s government, policymakers, and stakeholders must reconsider how resources are distributed to ensure equitable healthcare access. The findings highlighting disparities in terms of availability of trained staff and guidelines on NCDs is extremely important because poor knowledge and expertise of front-line healthcare professionals have already been identified as a major barrier to NCD care in numerous studies in Sub-Saharan Africa . These areas should be improved and addressed simultaneously as they have been shown to be cost-effective in terms of health care delivery . Lastly, there is an urgent need to step up cervical cancer screening services to make them widely available as part of routine care at all levels. A recent study revealed increasing trends in cervical cancer incidence in Sub-Saharan Africa, attributable to a lack of screening and prevention services .
Strengths and weaknesses of the study
One of the strengths of this study is that it examined a sample of facilities spanning across all geographic regions of Kenya, ensuring national representativeness in terms of general health facilities characteristics within the country’s health system. A further strength was that the data were collected using an adapted WHO-PEN questionnaire, nevertheless, with a focus on NCDs. This tool is increasingly being used in other LMICs, allowing our results to be comparable with other studies. However, some limitations should be acknowledged when interpreting the findings of this study. Firstly, like any other survey as opposed to a census, there is an inherent risk of sampling bias. In the present study, steps were taken to ensure that the sampling design was robust and sample weights were applied to account for disproportionate selection of facilities. Another limitation was on those domain tracer items where the information could not be verified by visual observation. It is important to bear in mind the possible bias in these responses since respondents may have given a more favorable perspective of their facilities, leading to an underestimation of the gaps. At the same time, it can also be difficult to judge if respondents tended to exaggerate the gaps in their respective facilities to attract attention. Finally, this was a cross-sectional study, meaning that causal effects could not be inferred and only associations were reported. Despite these limitations, the findings of this study add valuable insights to the growing body of knowledge, revealing important gaps and how a fragmented approach can frustrate or slow down the progress towards improving NCDs services at all levels irrespective of existing health systems structures. This evidence could be used to help improve the management of NCDs in low-resource settings.