Access, Bottlenecks, Costs, and Equity (ABCE) project.

1. Access, Bottlenecks, Costs, and Equity (ABCE)
Understanding the Costs of and Constraints to
Health Service Delivery in Kenya
On behalf of the ABCE research team
Institute for Health Metrics and Evaluation | Action Africa Help-International
January 2015

2. Overview
• Overview of the ABCE project in Kenya
• Key findings
o 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

3. Overview of the ABCE project in Kenya

4. Overview of the ABCE project in Kenya
ABCE 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

5. Overview of the ABCE project in Kenya
ABCE Facility Survey
• Primary data collection from a
nationally representative sample
of 254 facilities
• Collected data on a full range of
indicators
o Inputs, finances, outputs, supply-
side constraints and bottlenecks,
indicators for HIV care
• Randomly sampled a full range of
facility types
o National and provincial hospitals,
district and sub-district hospitals,
maternity homes, health centers,
clinics, dispensaries, VCT centers,
drug stores or pharmacies, and
DHMTs

6. Overview of the ABCE project in Kenya
Clinical 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

7. Overview of the ABCE project in Kenya
Patient 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.

8. Key findings from the ABCE project in Kenya
Facility capacity and service provision

9. Facility capacity and service provision
Availability 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 ownership
o 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

11. Facility capacity and service provision
Gaps 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).
Service
Facilities reporting
capacity
Facilities with
functional capacity
Antenatal care 89% 12%
General surgery
services
58% 13%

12. Facility capacity and service provision
Gaps 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).

13. Facility capacity and service provision
Gaps in reported and functional capacity for ANC, 2012

14. Facility capacity and service provision
Availability of and deficiencies in physical capital
• Power supply
o 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 sanitation
o 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 communication
o 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.

15. Facility capacity and service provision
Availability of and deficiencies in physical capital, 2012

16. Facility capacity and service provision
Availability of equipment across platforms
• Individual types of equipment
o 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.

18. Facility capacity and service provision
Availability of recommended equipment for level of care, 2012
Based on a subset of items from the WHO SARA survey

19. Facility capacity and service provision
Availability 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.

20. Facility capacity and service provision
Availability of recommended pharmaceuticals for level of care, 2012
Based on the 2010 EML list

21. Facility capacity and service provision
Capacity 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,
meningitis
o 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.

22. Facility capacity and service provision
Capacity for disease-specific case management, 2012

23. Facility capacity and service provision
Vaccine 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.

24. Facility capacity for service provision
Vaccine storage temperature for immunization services, 2012

25. Facility capacity and service provision
Capacity 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.

26. Facility capacity for service provision
Capacity to test for and treat malaria, 2012

27. Facility capacity and service provision
Human 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.

28. Facility capacity and service provision
Human resources for health: personnel composition, 2011

29. Facility capacity and service provision
Human resources for health: district and sub-district hospitals, 2011

30. Facility capacity and service provision
Human resources for health: public health centers, 2011

31. Facility capacity and service provision
Outputs, 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.

32. Facility capacity and service provision
Outputs: average outpatient visits, by platform, 2007-2011

33. Facility capacity and service provision
Outputs: average inpatient visits, by platform, 2007-2011

34. Facility capacity and service provision
Outputs: average ART visits, by platform, 2007-2011

35. Key findings from the ABCE project in Kenya
Non-HIV patient perspectives

36. Non-HIV patient perspectives
Patient 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.

37. Non-HIV patient perspectives
Patient reports of expenses associated with facility visit, 2012

38. Non-HIV patient perspectives
Levels 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 Kshs
in user or registration fees.

39. Non-HIV patient perspectives
Levels of patient medical expenses, by facility, 2012

40. 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.

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

42. 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).

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

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

45. Key findings from the ABCE project in Kenya
Efficiency and costs of care

46. Efficiency and costs of care
Estimating 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

47. Efficiency and costs of care
Average 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).

48. Efficiency and costs of care
Average 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.

49. Efficiency and costs of care
Efficiency 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.

50. Efficiency and costs of care
Efficiency scores across platforms, 2007-2011

51. Efficiency and costs of care
Estimated 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.

52. Efficiency and costs of care
Estimated potential for expanded service production, 2011

53. Efficiency and costs of care
Cross-country comparison of efficiency
• Other countries involved in the ABCE project showed more
potential for expanded service provision, given observed
resources, than Kenya.

54. Efficiency and costs of care
Estimating 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.

55. Efficiency and costs of care
Average 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.

56. Efficiency and costs of care
Average facility cost per visit, across outputs and by platform

57. Efficiency and costs of care
Cross-country comparison of output costs
• Kenyan facilities averaged the least expensive production cost
per outpatient visit and ART visit (excluding the cost of ARVs).

58. Key findings from the ABCE project in Kenya
A focus on HIV: service provision and patient characteristics

59. HIV service provision and patient characteristics
ART 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.

60. HIV service provision and patient characteristics
ART regimen at initiation, 2008-2012

61. HIV service provision and patient characteristics
ART regimen at initiation, by facility, 2011-2012

62. HIV service provision and patient characteristics
Patient 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.

63. HIV service provision and patient characteristics
WHO stage at initiation, 2008-2012

64. HIV service provision and patient characteristics
WHO stage at initiation, by facility, 2011-2012

65. HIV service provision and patient characteristics
Patient 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.

66. HIV service provision and patient characteristics
CD4 cell count at initiation, 2008-2012

67. HIV service provision and patient characteristics
Facility 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.

68. HIV service provision and patient characteristics
Facility availability of patient clinical information

69. HIV service provision and patient characteristics
Facility 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%.

70. HIV service provision and patient characteristics
Facility 12-month retention rates for ART patients, 2011

71. HIV service provision and patient characteristics
ART 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%).

72. HIV service provision and patient characteristics
ART patient reports of expenses associated with visit, 2012

73. HIV service provision and patient characteristics
ART 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 shorter
wait 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.

74. HIV service provision and patient characteristics
ART wait times at facilities, by platform, 2012

75. HIV service provision and patient characteristics
ART 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.

76. HIV service provision and patient characteristics
ART patient overall ratings of facilities, by platform, 2012

77. HIV service provision and patient characteristics
Average ART patient ratings of facility indicators, by platform, 2012

78. HIV service provision and patient characteristics
Efficiency 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.

79. HIV service provision and patient characteristics
Efficiency scores for facilities providing ART

80. HIV service provision and patient characteristics
Estimated 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).

81. HIV service provision and patient characteristics
Estimated potential for increased ART visits given resources

82. HIV service provision and patient characteristics
Cross-country comparison of ART efficiency
Kenya showed potential for expanded ART provision, given
observed resources, but at a lesser magnitude than Zambia.

83. HIV service provision and patient characteristics
Projected facility ART costs: analytical approach
• Four streams of data were used to project ART costs
1. Average facility cost per ART visit, excluding ARVs, based on the ABCE
sample
2. Average number of annual visits observed for new and established ART
patients in 2011, as extracted from clinical charts
3. The ARV regimens of ART patients in 2011 extracted from clinical charts
4. The ceiling ARV prices for 2011 published by the Clinton Health Access
Initiative (CHAI)
• Analytical steps for projecting ART costs
1. 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.

84. HIV service provision and patient characteristics
Projected 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

85. HIV service provision and patient characteristics
Projected facility costs for ART, 2011

86. HIV service provision and patient characteristics
Cross-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%).

87. Using ABCE work and findings for policymaking

88. Using ABCE for policymaking
Identifying 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

89. Using ABCE for policymaking
ABCE Kenya policy report
http://www.healthdata.org/dcpn/kenya

90. Conclusions

91. Conclusions
Facility 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.

92. Conclusions
Facility 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).

93. Conclusions
Patient 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.

94. Conclusions
Facility 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%).

95. Conclusions
Facility-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.

96. Conclusions
Priority 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.

97. Thank you
http://www.healthdata.org/dcpn/kenya