SU+ @ Strathmore University Library Electronic Theses and Dissertations This work is availed for free and open access by Strathmore University Library. It has been accepted for digital distribution by an authorized administrator of SU+ @Strathmore University. For more information, please contact library@strathmore.edu 2021 Examining private sector engagement in provision of public health services towards universal health coverage: a case study of Kisii County. Mounde, Mokaya Isaiah Strathmore Business School Strathmore University Recommended Citation Mounde, M. I. (2021). Examining private sector engagement in provision of public health services towards universal health coverage: A case study of Kisii County [Thesis, Strathmore University]. http://hdl.handle.net/11071/12948 Follow this and additional works at: http://hdl.handle.net/11071/12948 https://su-plus.strathmore.edu/ https://su-plus.strathmore.edu/ http://hdl.handle.net/11071/2474 mailto:library@strathmore.edu http://hdl.handle.net/11071/12948 http://hdl.handle.net/11071/12948 Examining Private Sector Engagement in Provision of Public Health Services Towards Universal Health Coverage: A Case Study of Kisii County Mounde Mokaya Isaiah MBA-HCM 93527 Research Thesis submitted in partial fulfillment of the requirements for the degree of Master of Business Administration Healthcare Management at Strathmore University Strathmore University Business School Nairobi, Kenya July 2021 ii Declaration I declare that this work has not been previously submitted and approved for the award of a degree by this or any other University. To the best of my knowledge and belief, the thesis/dissertation (use as appropriate) contains no material previously published or written by another person except where due reference is made in the thesis/dissertation itself. No part of this thesis may be reproduced without the permission of the author and Strathmore University. Mounde Mokaya Isaiah Admission number: 93527 ……………………………….. [Signature] 27th July, 2021……………….. [Date] Approval Supervisor: Dr. Francis Wafula Senior Lecturer, Healthcare Management Strathmore University Business School ……………………………….. [Signature] 14th June, 2021……………….. [Date] iii Abstract For Kenya to achieve universal health coverage (UHC) by year 2022, the national and county governments must strengthen engagement with the private sector. Yet there is lack of clarity on private sector engagement across counties. This study sought to describe engagement and impact in Kisii County. Specifically, the study sought to describe the private sector engagement models in Kisii, examine achievements and challenges of engaging the sector in meeting public healthcare goals, and explore management views on the perceived impact of private sector engagement. A multiple methods approach was taken, with data collected from 62 employees of the Kisii county health department and the private sector. The quantitative component entailed collecting survey data from 52 participants (21 public, 31 private). The qualitative component entailed 10 in-depth interviews (five each for public and private). Findings indicated that whereas a myriad of private sector engagement models were employed, the public-private partnership model was most preferred. Engagement achievements included public sector getting human resources from the private sector; technical and capacity building support; and technological and financing support from the private sector. Engagement challenges included difficulty in regulating and holding the private actors accountable under the partnership arrangements; difficulty in engaging the private sector in non-profit initiatives; and county government inability to sustain programmes initiated by the private sector. Overall, private sector engagement was perceived to have had a positive impact on progress towards UHC in Kisii across all six-health system building blocks, namely, governance, health work force, financing, service delivery, healthcare technology and access to medicines. Among others, the study recommends that county governments should have a central role to play in targeting and identifying households for National Hospital Insurance Fund (NHIF) enrolment and that national governments ought to avail financial resources to facilitate increased population coverage through the NHIF in keeping with universal health coverage. The study also recommends that the Kenyan government should increase public financing of the health sector at the county level. By dedicating 15% of the national budget towards healthcare for instance, there will be an uplift in the healthcare system enough to realize the Universal Healthcare Coverage as per the Abuja declaration of 2001 to which Kenya is a signatory. iv Table of contents Declaration ...................................................................................................................................... ii Abstract .......................................................................................................................................... iii Table of contents ............................................................................................................................ iv List of Figures .............................................................................................................................. vii List of Tables ............................................................................................................................... viii List of Abbreviations ..................................................................................................................... ix Chapter 1 Introduction to the Study ................................................................................................ 1 1.1 Introduction ........................................................................................................................... 1 1.2 Background to the study ....................................................................................................... 1 1.3 Problem Statement ................................................................................................................ 3 1.4 Research Objectives .............................................................................................................. 4 1.4.1 Overall Objective ........................................................................................................... 4 1.4.2 Specific Objectives ........................................................................................................ 5 1.5 Research Questions ............................................................................................................... 5 1.6 Scope of the Study ................................................................................................................ 5 1.7 Significance of the Study ...................................................................................................... 5 Chapter 2 Literature Review ........................................................................................................... 7 2.1 Introduction ........................................................................................................................... 7 2.2 Theoretical Foundation ......................................................................................................... 7 2.1.1 Agency Theory.......................................................................................................... 7 2.2.1 Contract Theory ............................................................................................................. 8 2.3 Potential Application of Theory in Understanding Private Sector Engagement ................ 10 2.4 Public Health Service in Kenya .......................................................................................... 10 2.5 Private Health Service in Kenya ......................................................................................... 11 2.6 Universal Healthcare Coverage .......................................................................................... 12 2.7 Empirical review ................................................................................................................. 13 2.7.1 Models Used for Private Sector Engagement .............................................................. 13 2.7.2 Achievements and Challenges of Private Sector Engagement .................................... 16 2.7.3 Impact of Private Sector Engagement on achieving UHC........................................... 17 2.8 Summary of Literature Gaps ............................................................................................... 18 2.9 Conceptual Framework ....................................................................................................... 19 v Chapter 3 Research Methodology ................................................................................................. 20 3.1 Introduction ......................................................................................................................... 20 3.2 Research Design.................................................................................................................. 20 3.3 Population and Sampling .................................................................................................... 20 3.3.1 Sampling ...................................................................................................................... 21 3.4 Data Collection Methods .................................................................................................... 22 3.4.1 Quantitative method ..................................................................................................... 22 3.4.2 Qualitative method ....................................................................................................... 22 3.5 Data Analysis ...................................................................................................................... 22 3.5.1 Quantitative data .......................................................................................................... 23 3.5.2 Qualitative Data ........................................................................................................... 23 3.6 Research Quality – Validity, Reliability and Objectivity of the Research ......................... 23 3.6.1 Validity ........................................................................................................................ 23 3.6.2 Reliability ..................................................................................................................... 23 3.6.3 Objectivity.................................................................................................................... 23 3.7 Ethical Consideration .......................................................................................................... 24 Chapter 4 Results .......................................................................................................................... 25 4.1 Introduction ......................................................................................................................... 25 4.2 Response Rate ..................................................................................................................... 25 4.3 Respondent Demographic Characteristics .......................................................................... 25 4.4 Form of Private Sector Engagement with the County Government ................................... 27 4.5 Perceived achievements and Challenges in Engaging the Private Sector ........................... 33 4.6 Manager Perceptions on the Impact of Private Sector Engagement ................................... 35 4.6.1 System Governance ..................................................................................................... 35 4.6.2 Improved Health Work Force ...................................................................................... 36 4.6.3 Health Financing .......................................................................................................... 37 4.6.5 Improved Technology ............................................................................................. 38 4.6.6 Access to Quality Drugs ......................................................................................... 39 4.7 Existence of Engagement Framework............................................................................ 39 Chapter 5 Discussion .................................................................................................................... 41 5.1 Introduction ......................................................................................................................... 41 5.2 Summary of Key Findings .................................................................................................. 41 vi 5.3 Discussion of Results .......................................................................................................... 42 5.4 Study Limitations ................................................................................................................ 48 5.5 Conclusion .......................................................................................................................... 49 5.6 Recommendations ............................................................................................................... 50 5.6.1 Policy Recommendations............................................................................................. 50 5.6.2 Management Recommendations .................................................................................. 51 5.7 Suggestions for Further Studies .......................................................................................... 52 References ..................................................................................................................................... 45 Appendices .................................................................................................................................... 53 vii List of Figures Figure 2.1Conceptual Framework ................................................................................................ 19 Figure 4.1Private Sector Engagement Models.............................................................................. 30 Figure 4.2 Legal Framework for Private and Public Sector Engagement .................................... 31 Figure 4.3 Frequency of Public-Private Sector Dialogue ............................................................. 32 Figure 4.4 Areas of Engagement in Public-Private Sector Dialogue ............................................ 32 viii List of Tables Table 3.1Target Population ........................................................................................................... 20 Table 3.2 Sample size distribution ................................................................................................ 21 Table 4.1Distribution of Respondents by Gender ......................................................................... 25 Table 4.2 Distribution of Respondents by Age ............................................................................. 26 Table 4.3 Distribution of Respondents by Education Level ......................................................... 26 Table 4.4 Distribution of Respondents by Level of Management ................................................ 27 Table 4.5 Distribution of Respondents by Organization .............................................................. 27 Table 4.6 Form of Private Sector Engagement with the County Government ............................. 28 Table 4.7 Pillars of Private Sector Engagement ........................................................................... 29 ix List of Abbreviations CBO Community Based Organization HICs High-Income Countries KSHS Kenya Shillings LMICs Low- and Middle-Income Countries MoH Ministry of Health MoU Memorandum of Understanding NGOs Non-Governmental Organizations NHIF National Hospital Insurance Fund PPPs Public-Private Partnerships PSE Private Sector Engagement SDG Sustainable Development Goals UHC Universal Health Coverage UK United Kingdom UN United Nations WHO World Health Organization YRS Years 1 Chapter 1 Introduction to the Study 1.1 Introduction This section builds the case for the study by providing background information, defining the problem, outlining the study objectives and discussing the significance of the study. 1.2 Background to the study Globally, countries are striving towards achieving Universal Health Coverage (UHC). UHC refers to a system that allows all members in a society to access essential health services without direct financial barriers. The definition embodies three related objectives: equity in access to health services based on need rather than ability to pay; that the quality of health services is good enough to improve overall health; and that there are financial risk protection mechanisms to ensure that persons are not impoverished due to seeking healthcare (World Health Organization, 2013). Based on international human rights laws, countries are free to choose any mix of public and private involvement in the health sector (World Health Organization, 2013). The private health sector includes a wide range of actors offering a variety of services. Private actors include commercial (for-profit) providers and Non-Governmental Organizations (NGOs), all ranging from multinational corporations to small private practitioners operating clinics, pharmacies and labs. The World Bank defines the private health sector to include all actors outside of government such as for-profit, not-for-profit, formal and informal entities (Preker & Harding, 2003). Private healthcare service provision is a substantial and growing sector that is capturing an increasing share of the health market across the world, playing a major role in both High-Income Countries (HICs) and Low- and Middle-Income Countries (LMICs) (Hahn, 2014; Reading, 2018). In the United Kingdom (UK), for instance, the National Health Service, a state-funded universal health care system, has a sizeable private sector engagement component, and is increasingly opening services up to competition to improve efficiency (Hahn, 2014). In India for instance, 70% of healthcare services are provided by the private sector (Reading, 2018). 2 The roles and activities of private sector actors in healthcare include the provision of healthcare services, management of health institutions, production of health products and technologies and financing. In HICs, private provision usually entails care by well-trained professionals in settings with sophisticated equipment (Palmer, 2002). These roles and activities may also be carried out within a publicly run health care system for example, case in the United Kingdom, where private actors have a role in nursing homes for persons with disabilities under the National Health Service. According to the World Bank, the private sector delivers roughly half of Africa’s health products and services (World Bank Group, 2017). Reasons for its popularity include perceived inefficiency and lack of quality in the provision of public health care, increased costs and reduced budgets for health care due to the financial crisis, and encouragement by international financial institutions to rely on private actors to decrease the burden on national budgets (World Bank, 2017). Accordingly, there has been an increase in private sector engagement across governments globally, which is defined as the systematic and deliberate collaboration of the private sector and the government to advance national health priorities forward, beyond individual programs and interventions (World Bank Group, 2017). Governments employ various models in their private sector engagement, including Public Private Partnerships (PPPs), social marketing, dual practice regulation, sector- wide approach, voucher programs, contracting-out, public-private mix approach and financing (Whyle & Olivier, 2016). Under sustainable development, United Nations (UN) member states committed to working towards achieving universal health coverage by 2030 (Partnership & Annual, 2019). As a result, Kenya adopted UHC as one of the priority projects, targeting to have all Kenyans covered by year 2022. Both the country’s Constitution and Vision 2030 emphasize the right to healthcare (The Government of Kenya, 2010). Under Vision 2030 (GOK, 2007), Kenya’s development blueprint, UHC is concerned with ensuring access to quality healthcare by increasing structural and resource capacity to handle the growing population. With health tourism being one of the flagship Vision 2030 projects, Kenya is expected to position itself as a destination for specialized health and medical services. With only 22% of Kenyans having health insurance, private sector involvement would supplement and reinforce the services of the public sector. This would help the Kenyan government achieve its goal of 100% coverage by 2022 (Ministry of Health, 2016). For Kenya to 3 achieve UHC, strategic initiatives have to be put in place. According to a 2019 report by Informa Markets, the private sector will be key in Kenya’s achievement of UHC. Through its financial and innovative capability, the private sector can play a crosscutting role in expanding the UHC and improving the quality of care. Country reports show that the main factors underlying the expansion of the private health sector include the perception of low quality at public facilities, higher private sector focus on customer satisfaction, absence of public health facilities in underserved areas, large rural-to-urban migration lowering the public sector’s ability to offer services effectively. And, low government spending on health contributing to high out-of-pocket spending (Stallworthy, Boahene, Ohiri, Pamba, & Knezovich, 2014). While most obligations identified in international human rights law fall on States, there are clear obligations for non-state actors in health. However, given that such actors do not have formal legal obligations, an exploration of how the private-sector engagements may be aligned to advance UHC is necessary in order to realize synchrony in the tripartite relationship between the right to health, private sector involvement, and the public sector hence the present study. 1.3 Problem Statement The private sector plays an important role, especially in the financing and services delivery functions, as well as supplying essential products and technologies (Blumenthal & Hsiao, 2015). Studies suggest a strong preference for private health providers in LMICs for various reasons, including the perception of good quality care, focus on customer satisfaction, absence of public health facilities in some underserved areas, high rural-to-urban migration lowering the public sector’s ability to offer services effectively, and, low government spending on health contributing to high out-of-pocket spending (Stallworthy et al., 2014). In Kenya, despite increased private sector engagement activity, worries persist over their role and impact, including concerns over poor information sharing, weak government capacity to lead engagement with private actors, lack of financing, mismatched organizational styles and differing priorities, lack of clear private sector engagement strategy and corruption (Jane, 2014). This is 4 made worse by an overall lack of trust between the two sectors, poor coordination, and limited interaction between public and private sector players (Okech & Lelegwe, 2015). To address the challenges, the SDG Partnership Platform was established in Kenya to promote interaction, coordination and communication across sectors. This has helped to formalize policy arrangements, allowing private actors to be involved in policy design. Despite the efforts, there are concerns that communication and engagement remains poor, particularly at sub-national level. There is also lack of clarity on the role that the private sector is playing across counties, and the extent of their involvement in health services and UHC broadly (United Nations Development Programme, 2019). The Kisii County through its health department strategic plan 2018/23 identifies healthy lives and promotion of well-being for all at all ages as the ultimate goal which anchors the pillars of UHC. Despite the robust strategies put in place by the county government to improve health services, the review of the previous strategic plan brings forth outstanding challenges among which are increased demand due to increasing population surpassing the current supply, weak PPP and partner engagement framework among others (Kisii County Intergrated Plan, 2018). Coupled with scanty pertinent empirical literature, it is the foregoing reported challenges in private sector engagement towards UHC in Kenya in general and Kisii County in particular, that warranted the present study. The study particularly set out to examine the role of private sector engagement in provision of public health services towards universal health coverage with reference to Kisii County. Findings in this regard would inform recommendations towards addressing the identified challenges for an effective private sector engagement towards universal health coverage in Kisii County, and its generalization to Kenya. 1.4 Research Objectives 1.4.1 Overall Objective To examine private sector engagement in provision of public health services towards universal health coverage in Kisii County. 5 1.4.2 Specific Objectives i. To describe the private sector engagement models used in Kisii County ii. To examine achievements and challenges with private sector engagement in Kisii County iii. To explore in-depth the health system managers’ perceptions on the impact that private sector engagement has had (if any) on promoting UHC in Kisii County 1.5 Research Questions i. What models are used for private sector engagement in Kisii County? ii. Are there any achievements or challenges experienced in engaging the private sector to meet public health goals in Kisii County? iii. How do health systems manager perceive the impact of private sector engagement in promoting progress towards UHC in Kisii County? 1.6 Scope of the Study The study was limited to private sector engagement in the provision of public health services in Kisii County. The study was conducted within Kisii County, and used county managers and private healthcare partners as respondents. The geographical scope of the study included the entire Kisii County. This entailed both the central business district where the county government is located, from which county managers were drawn for participation, and the nine (9) sub-counties from which respondent private healthcare partners were sampled. The nine sub-counties include South Mugirango, Bomachoge Chache, Bomachoge Borabu, Bobasi, Kitutu Chache south, Kitutu Chache North, Nyaribari Masaba, Nyaribari Chache and Bonchari. The study was conducted between March and April 2020. 1.7 Significance of the Study Study findings contribute to the existing body of knowledge on universal health coverage in Kenya and act as a reference point for research looking at the role of the private sector in UHC. Findings also inform the Kisii County government on the achievements and challenges encountered in trying to include the private sector in meeting UHC, a pubic goal. 6 Policy makers both at the national MoH and the County governments may also find the study helpful in thinking through and designing policy solutions that seek to take a whole market approach, particularly those that are focused on achieving UHC. 7 Chapter 2 Literature Review 2.1 Introduction This chapter discusses the theoretical foundation, empirical literature and the conceptual framework to guide the study. 2.2 Theoretical Foundation Various theories underpin the relationship between private sector engagement and provision of public services. Prominent among these theories and of particular relevance to this study are the Principal-Agent Theory (Agency Theory) and the Contract Theory. 2.1.1 Agency Theory The Agency Theory was first proposed by (Coase, 1937), whose concern was understanding why firms exist and the nature of relationships between actors with varying levels of information. The concept was further developed in respect to property rights and the theory of the firm (Alchian & Demsetz, 1972). The theory addresses the relationship between the ‘principal’, normally the shareholders or owner of an organization or the responsibility holder for the strategic roles of an institution, and the agent, normally the management of an organization tasked with delivering the organization’s mandates in the best interest of the principal. The theory is concerned with resolving problems that exist where there is information asymmetry (Jensen & Meckling, 1976). Principle- agent arrangements are inherently problematic because of diverse interests and levels of knowledge across actors. Agency theorists often contend that private sector engagement in the provision of for public health services exacerbate the principal-agent problem, where diverse interests and varying levels of information can result in the agent serving less of the principal’s (and by extension, the society’s) purposes, and more of its own purposes (Berezin, Sergi, & Gorodnova, 2018). For this reason, contractual arrangements must ensure proper alignment of interests of the principal and the agent, usually through a variety of ways, most notably, minimizing the information barrier (which means the principal must have ways of monitoring the agent, and ensuring whatever they engage in serves the greater societal good). 8 The Agency theory has been criticized by a number of scholars on various grounds, including Perrow (1986) who observed that the theory is not concerned about the principals, who exploit, shirk and deceive the agents. According to Perrow (1986), some principals act opportunistically by pulling naïve agents into work with dangerous working environments and without any scope for infringement. Further, Pepper and Gore (2012) criticized the agency theory by arguing that the standard agency theory only lays emphasis on agency cost, the agent and principal theory and parties’ interests’ realignment with a view to minimize the agency problem. According to Pepper and Gore (2012), the main constituent of the principal–agent association are the agents and that their performance depends mostly upon their motivation and ability. In this study, the public sector, tasked with delivering UHC, can be considered the principal, whereas the private sector, often rich with information, resources and technological capacity, can be considered the agent chosen to help the principal achieve its mandate. Agency theory thus underpinned the contractual relationship between the private sector and the public sector. The theory was particularly instrumental in the understanding of whether or not the interests inherent among both private sector and public sector actors are aligned and whether this alignment is manifested in the achievements of private sector engagement. The theory was also used to elucidate whether or not the diversity of interests thereof results in agency problems and whether or not the problems are manifested in the challenges of private sector engagement. 2.2.1 Contract Theory Contract Theory provides further developments on the Agency Theory concepts by modelling the details of the relationship of contracts between parties (Athias, 2007). Contract Theory holds that ownership, specifically the assignment of residual rights, influences the incentives of the engagement parties and will stimulate productive levels of investment. In other words, a properly empowered agent will act in the interests of the principal (Hart, 2003). In economics, Contract Theory studies how economic actors can and do construct contractual arrangements, generally in the presence of information asymmetry. In a costless world where transaction costs are zero and parties can write complete contracts, contracts would not need to be modified or updated since everything would be anticipated and 9 planned for in advance, or there would be no cost for engagement of a third party to resolve problems (Hart, 2003). In reality, however, transaction costs are pervasive and substantial, so long- term contracts are always incomplete. Hart defined an incomplete contract briefly as one that “contains gaps or missing provisions”. For an incomplete contract, events will occur that make it desirable for the parties to depart from what was specified in the contract: they may want to revise the contract; they may disagree about the meaning of the contract; and lastly, disputes may occur so parties will need to bring in a third party to determine a solution (Athias, 2007). Contract Theory also employs the concept of a complete contract, which is conceptualized as a contract that stipulates the legal ramifications of every possible state of affairs (Athias, 2007). When unexpected eventualities arise, the contracting parties must bargain over the best course of action. In such instances, asset owners possess greater bargaining power, which stimulates them to invest. As such, the asset ought to be possessed by the party with the most important investment. Accordingly, Hart (2003) observed that giving one party bargaining power is more effectual compared to spreading bargaining power across several parties. In criticizing the Contract Theory, Coase (1993) opined that the society is not costless, arguing that the so-called transaction costs may be costs of finding the adequate prices; costs of signing and the negating the contract; costs of searching the transaction partners; information costs emanating from stopping the lack of information during interactions; decision costs emanating from the different parties’ aims for instance, time delay; bargaining costs, for instance, costs of negotiations costs of arranging the transactions; costs of adjusting to the varying conditions; and costs of expired payments and fulfilments. As such, the Contract Theory is built on the grounds being criticized and completed by Coase, who advanced alternative theories often called post- Coasian theories (Kapas, 1999). Against this background, Contract Theory was employed to understand how private sector engagement stimulates various levels of investment among private actors towards delivering UHC, through the assignment of roles and contractual arrangements in PPPs, contracting-out, public- private mix approach, dual practice regulation and Sector-Wide Approach (SWAps). 10 2.3 Potential Application of Theory in Understanding Private Sector Engagement Both theories are pertinent in understanding the association between the various models of private sector engagement and realization of UHC goals in Kisii county. Parties may for instance encounter agency problems anticipated in contractual relationships underpinned by the Contract Theory. The models are expected to bring forth agency problems whereby private sector organizations may be tasked or obligated by the public sector to deliver certain public health services either for free or at subsidized rates, which the private sector may be reluctant to deliver owing to their business model. In anticipation of the foregoing agency problems, the parties may seek to enter into formal contractual agreements in line with Contract Theory. 2.4 Public Health Service in Kenya The Kenyan health system defines six levels of the hierarchy, as follows: level 1, community services; level 2, dispensaries and clinics; level 3, health centres and maternity and nursing homes; level 4, sub-county hospitals and medium-sized private hospitals; level 5, county referral hospitals and large private hospitals; and level 6, national referral hospitals and large private teaching hospitals. PHC services are primarily provided at levels 1 to 3 (World Health Organization, 2017). Public PHC facilities are governed by health facility committees, which include the facility in- charge and community representatives. For private PHC facilities, government oversight is provided through regulation, implemented through eight regulatory agencies (IFC and World Bank, 2019). According to the Kenya Health Policy (2014–2030), the 10 leading causes of death in Kenya are HIV-related ailments (29%), perinatal conditions (9%), lower respiratory tract infections (8%), tuberculosis (6%), diarrhoeal diseases (6%), malaria (5%), cerebrovascular diseases (3%), ischaemic heart disease (3%), road traffic accidents (2%) and violence (2%). The country has made remarkable progress in improving key health indicators over recent years. The government’s health goal is attainment of universal health care coverage for key services, including maternal, neonatal and child health services. Public primary health facilities have been reported to be pro-poor, particularly across rural locations (World Health Organization, 2017). 11 In the public sector, the 47 county governments deal with service provision at the local level, while the national level is concerned with policy and the referral hospitals. Taking all the healthcare systems in Kenya together, the fundamental shortcoming is the mismatch between needs and the available care, in particular specialist care and the workforce including doctors and technicians, needed to run it. The Kenya Medical Supplies Authority (KEMSA) is the public agency for medicines, supplying commodities based on orders received from counties. At county level, the county pharmacist is responsible for pooling orders from individual health care facilities, aggregating these, and making orders directly to KEMSA (Kamau, Mukui, & Kimato, 2020). 2.5 Private Health Service in Kenya Kenya’s private sector is one of the most developed and dynamic in Sub-Saharan Africa. In the health sector, where the leading causes of death are HIV/AIDS, acute respiratory infection (ARI), diarrheal diseases, and malaria (WHO, 2019), the private commercial (for-profit) sector and the not-for-profit sector play critical roles in preventing and treating disease. Kenya’s healthcare system is made up of several systems: public, private and faith-based or NGO. About 48% are public and operate under the Ministry of Health, 41% are in the private sector, 8% are faith-based health services, and 3% are run by NGOs. Whereas healthcare in public hospitals is free for some services, such as maternity care, and for those with national health insurance, in-patient treatment, healthcare provided by private hospitals, faith-based institutions or NGOs usually comes at a cost and charges will vary (The United States Agency for International Development (USAID), 2019). The private health sector is increasingly viewed as critical to meeting the growing demand for financing and delivery of health care services, including HIV, in Kenya. Approximately 37 percent of all health spending occurs in private facilities (WHO, 2019). The private health market has dramatically grown over the last two decades and is an important source for care across various segments of the population. For example, 47 percent of poor Kenyans use a private facility when a child is sick and a third (1/3) of couples obtain their family planning methods from the private commercial sector. Further, 10 percent of health care spending goes to NGOs or faith-based facilities for family planning, while a quarter (1/4) of people living with HIV and AIDS access treatment from the commercial private sector (IFC and World Bank, 2019). 12 Kenya has many legal and regulatory components in place to facilitate growth of the private health sector. There are effective regulatory schemes for health professionals, and the concept of continuing professional education is well established. Moreover, all of the Boards of Registration have procedures in place to withdraw the practice licenses of the health professionals they supervise (Kamau et al., 2020). But there are still areas that need to be strengthened to improve the quality of services, including lack of enforcement by the professional boards result in a highly unregulated private health sector; unqualified health professionals continue to practice privately in the country, despite some well publicized crackdowns; responsibility for licensing of private health facilities is spread across too many regulatory bodies, leading to inefficiencies and gaps in monitoring quality of care; and there is no non-governmental accreditation or certification for facilities and laboratories (USAID, 2019). 2.6 Universal Healthcare Coverage According to Universal Healthcare Coverage means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course (WHO, 2021). Currently, at least half of the people in the world do not receive the health services they need. About 100 million people are pushed into extreme poverty each year because of out-of-pocket spending on health. UHC strategies enable everyone to access the services that address the most significant causes of disease and death and ensures that the quality of those services is good enough to improve the health of the people who receive them (WHO, 2021). In Kenya, Universal Health Coverage is one of the “Big Four” strategic pillars declared by the President of Kenya which will see major policy and administrative reforms in the medical sector, to ensure everyone has access to quality and affordable medical coverage by 2022. The country is in the process of defining a Health Financing Strategy which will give impetus to Kenya’s journey towards universal health coverage (International Trade Administration, 2018). Opportunities here are for Public Private Partnerships (PPP’s) with the National Health Insurance Fund financing solutions will be required to meet the demands of the growing population and cater for the underserved regions. The government is also in the process of setting up Cancer Centers of 13 Excellence (CoE) in two national hospitals to provide affordable, quality cancer treatment in a bid to reduce the high number of patients seeking specialized treatment in other countries. This will also boost the country’s large medical tourism market in the East African region (Kariuki, 2020). Some impediments however, towards the realization of universal healthcare in the country. For instance, there are extreme regional differences in the quality and distribution of care, with the best facilities located in Kenya’s capital Nairobi, while the most underdeveloped facilities are in the North-Eastern Province and parts of the coastal region (Oraro & Wyss, 2020). Primary care facilities in rural areas often suffer from shortages of staff, essential drugs, and basic medical equipment. Some patients choose not to seek care due to the distance that they would have to travel to reach the nearest health facility. Only 30% of the rural population has access to health facilities within 4km of their home, compared with 70% of the urban population (Kariuki, 2020). 2.7 Empirical review 2.7.1 Models Used for Private Sector Engagement Various models of private sector engagement in the provision of public services that have been identified in the literature include: PPPs, social marketing, dual practice regulation, sector-wide approach, Voucher programs, contracting-out, public-private mix approach and financing (Whyle & Olivier, 2016). 2.7.1.1 Public Private Partnership Model PPPs is defined as: “arrangements where the public and private sectors both bring their complementary skills to a project, with varying levels of involvement and responsibility, for the purpose of providing public services or goods” (The World Bank, Asian Developtment Bank, & Inter-American Development Bank, 2009). The rise of PPPs worldwide is arguably evidence that traditional methods of infrastructure development are inadequate (Garvin & Bosso, 2008). PPP model is characterized by high level of engagement, risk transferring/ sharing between the parties, long-term contractual obligations ranging to up to 30 years and highly capital intensive (Hackworth, 2019). This model include: concession contracts, joint ventures, Rehabilitate Operate 14 Transfer (ROT) contracts and Build Operate Transfer (BOT) type contracts among others (Gaffney, Pollock, Price, & Shaoul, 1999). 2.7.1.2 Social Marketing Model Private sector utilizes their marketing and communication prowess in the public sector context with the aim of achieving behavior change through sale of products/services of high social or public health impact. Channels of distribution include: CBOs, NGOs, Public facilities like hospitals or schools. The private sector looks for external funding for such programs and complimented with government subsidies on the products/services offered. Social marketing can be used both downstream (as shown earlier) or upstream to influence behavior change among the policy formulators with the aim of influencing them to draft policies and regulation whose impact results in the intended behavior change (Firestone, Rowe, Modi, & Sievers, 2017). 2.7.1.3 Dual Practice Regulation Model This model involves bilateral engagement in formulating and enforcement of regulations aimed at controlling public sector health care providers offering services in the private sector and/or stopping the brain drain from public sector to private. Strategies employed in execution of this model include sanctions or incentives; the ultimate goal being rationalization of HRH across sectors but more importantly in the public sector (Whyle & Olivier, 2016). 2.7.1.4 Sector-Wide Approach (SWAps) Under the SWAps model, the government leads joint negotiations with the private sector, with the aim of pooling resources together for the common good of society. The process should always be steered by the government. The model entails private sector involvement in the planning, budgeting and expenditure processes. Ultimately, the government’s aim is to mobilize resources that are sufficient to serve specific goals. SWAps were introduced in early 90s following widespread dissatisfaction with the prevailing government – donor relationships. Over the years, SWAps gained popularity across countries. 15 They have been reported to have contributed to aligning, harmonizing and enhancing accountability between governments and donors (Peters, Paina, & Schleimann, 2013). A fifteen-year implementation of SWAp model in Bangladesh by the ministry of health and family welfare (Ahsan et al., 2016) saw government priorities getting both technical and funding support thus improving program designs and implementation strategies accelerating improvement of health outcomes. 2.7.1.5 Voucher Programs The voucher program model entails incorporating subsidies on the demand side of the healthcare equation, thus transferring the power to purchase from the providers to the service users, thereby overcoming barriers to uptake of services (Whyle & Olivier, 2016). Causes of low uptake of services include socio-cultural and socio-economic factors. Study on the community level impact of this model on utilization of reproductive services in Kenya showed increased uptake of facility based deliveries by poor women (Obare et al., 2013). Government therefore highlights areas where support is needed and the private sector selects few products/ goods which will now be based on the voucher program. 2.7.1.6 Contracting-out Model This model entails a government entering into a contract with a private entity to provide services or goods on behalf of the government. The private entity gets a fee in exchange. The contract terms govern execution of this model including the duration, terms of payment and termination. This simply therefore means the government purchases private sector services for the public to consume thus bringing along the process efficiencies experienced in the private sector. 2.7.1.7 Public-Private Mix Approach Model Private sector players meet under the umbrella of the government to devise strategies of combating particular issues, for instance, a disease outbreak. Outbreak of Coronavirus in China has led to concerted effort by governments and the private sector in laying down strategies of managing this disease which world health organization has declared a worldwide emergency. 16 2.7.1.8 Financing Model This model, usually no- contractual, experiences transfer of funds from the public sector to the private sector in exchange of service provision. This can be through direct grants or public insurance body like NHIF covering private sector services. 2.7.2 Achievements and Challenges of Private Sector Engagement Governments are increasingly challenged to provide sufficient funding for public infrastructure as a result of growing populations, urbanization, necessary network expansion and aging infrastructure assets (World Health Organization, 2013). In addition, the public sector often has to provide significant subsidies for healthcare however, it always operates under a deficit. Therefore, if structured correctly, private sector engagement can relieve this burden by activating priory untapped sources of funding from the national or international private sector. Significant positives have been registered across the world with PSE. This includes: Increased service utilization, improved service quality, enhanced access to services by the disadvantaged in society and reduced out-of-pocket costs for beneficiaries (Jacobs & Price , 2006; Meuwissen, Gorter & Knottnerus., 2006). In addition, there is increased coordination and alignment efforts in policy and programme design and implementation in countries adopting SWAp (Vaillancourt 2009; Negin & Martiniuk, 2012). PSE’s success especially SWAps depend heavily on the capacity and political will of the country’s government. As a result, great plans may not be effectively implemented due to competing priorities in LMIC. Marginalization of private sector in policy discussions and consideration of the expenditure and institutional frameworks has been on the rise complicating further the primary goal of the private sector engagement (Hill, 2002; Sundewall, Forsberg , & Tomson, 2006; Vaillancourt, 2009). Therefore, PSE achievements and challenges in LMIC will revolve around the following key thematic area: health sector plan, government ownership of processes, increased and streamlined funding availability/expenditure and long-term commitment by both parties, institutional capacity and good governance (Ahsan et al., 2016). 17 2.7.3 Impact of Private Sector Engagement on achieving UHC The overarching goal of the private sector engagement is to bring about a long-lasting positive impact on every parameter of the six health building blocks which are: effective governance, adequate financing, quality services, modern ICT, adequate supply of commodities and pharmaceutical products and adequate human resource for health. Governments can thus benefit from the expertise and technological knowhow, as well as the innovation capabilities of the private sector (The World Bank et al., 2009) in achieving UHC. The private sector is heavily dependent on correct cost estimates and revenue forecasts in order to minimize risk and to best predict financial returns. These non-governmental parties, which are driven by their experience and strong profit-driven nature, usually follow higher levels of quality assurance, when compared to the public sector. Further, the participation of private sector entities in the tendering process for instance, can lead to two advantages for governments according to (Garvin & Bosso, 2008): It can function as a filter for the public sector to detect and abandon white elephant infrastructure projects upfront, as they often simply do not attract private lenders and investors, who have carried out their own project analysis. It can also result in suggestions of innovative ideas by the private sector. If governments show flexibility in finding infrastructure solutions as well as accept unrequested proposals, the private sector can suggest innovative solutions to meet infrastructure challenges. A private lender or investor undertakes private sector engagement with the clear target to maximize profits and often does so by introducing measures, which can possibly enhance efficiency and effectiveness of the project, in order to optimize both revenues and costs (Iossa & Martimort, 2015). Governments can profit from this mindset of the private sector, by utilizing available scarce resources more efficiently and effectively. Additionally, these streamlined processes increase the likelihood that these services are provided in an economically sustainable manner and at affordable cost for the user, while still satisfying profit targets (Clarke, 2011). Moreover, private sector engagement allows governments to transfer operational roles to the private sector, while placing their focus on core public sector responsibilities such as regulation and monitoring. 18 2.8 Summary of Literature Gaps The foregoing review details empirical studies pertinent to private sector engagement and the provision of public health services in the context of the provision of universal health coverage. The reviewed literature attempt to link the various concepts explored in the present study, including the private sector engagement models, achievements and challenges. It however remains unexplored, the extent to which the private sector is involved in the provision of public health services towards universal health coverage in the Kenyan context, particularly the private sector engagement models, achievements and challenges thereof. Further, extant empirical literature is deficient in exploring the link between the anchoring theories and private sector role in the provision of universal health coverage in the country, hence the present study. 19 2.9 Conceptual Framework As illustrated in the conceptual framework (Figure 2.1), the model of PSE adopted define the contractual relationship between the public and private sector actors towards the realization of Universal Health Coverage as anticipated by both the Agency theory and Contract Theory. In tandem with Agency theory, the alignment of interests between the public and private sector actors was anticipated to result in achievements towards the realization of Universal Health Coverage while diversity and conflict of interests would result in challenges affecting the overarching Universal Health Coverage realization. Also, in accordance with Contract Theory, the various incentives in the models, or their lack thereof, would determine the private sector’s level of investment and involvement towards the realization of Universal Health Coverage. Figure 2.1Conceptual Framework 20 Chapter 3 Research Methodology 3.1 Introduction This chapter discusses the study methodology, specifically looking at the study design, sampling, research quality, data collection methods, data analysis methods and ethical concerns. 3.2 Research Design The study employed a mixed method approach, combining a questionnaire survey with in-depth qualitative interviews carried out with public and private sector actors. Mixed method approach was deemed adequate in the present study in order to complement quantitative data obtained from the questionnaire with qualitative information obtained from the in-depth interviews as well as for triangulation purposes. 3.3 Population and Sampling The target population for the study was administrative staff at the Kisii County Government Health Department distributed across three cadres including senior, middle and lower management and private partners engaged in Kisii County as tabulated below. Table 3.1Target Population Category Population County Government Senior Management 7 Middle Management (CHMT) 10 Lower Management (SHMT) 9 Private Sector Facilities (Focus Areas) HIV/AIDS/ TB/ Malaria/ RMNCAH NCD Emergency Response Private insurance (Britam) Adolescent and child health Health systems Management Community Strategy Total 27 2 1 1 3 1 1 62 {Source: Office of County Director of Health, Kisii County} 21 3.3.1 Sampling 3.3.1.1 Sampling in the qualitative study To determine a sample size in a qualitative part of the study, purposive sampling method was used, based on the respondents’ conversance or proficiency in the subject matter. Purposive sampling is a form of non-probability sampling whereby the researcher relies on their own judgment when selecting members of the target population to take part in their study. In this case therefore, Moser and Korstjens (2018) recommends 10 interviews to be sufficient. For the purposes of this study, and in consideration of saturation point, five interviews were considered drawn from public and similar numbers drawn from the private sector. 3.3.1.2 Sampling in the quantitative study The remaining 52 individuals from the population of 62 formed in its entirety the sample size for the quantitative part of the study participation. These included a census of 21 county government health department officials and 31 private sector partners engaged by the Office of County Director of Health, Kisii County. Distribution of the sample size was as shown in Table 3.2. Table 3.2 Sample size distribution Category Sample size County Government Senior Management 6 Middle Management (CHMT) 8 Lower Management (SHMT) 7 Private Sector Facilities (Focus Areas) HIV/AIDS/ TB/ Malaria/ RMNCAH NCD Emergency Response Private Insurance (Britam) Adolescent and child health Health systems Management Community Strategy Total 22 2 1 1 3 1 1 52 22 3.4 Data Collection Methods 3.4.1 Quantitative method To address study objective 1, data was collected using the 52 semi-structured questionnaires administered to the respondents directly. The questionnaire had two sections. Section A which covered respondents’ demographic information while section B contained both open and closed ended questions addressing objective 1 of the study. Questions sought to understand engagement models used by different actors in Kisii County. Questionnaire development was adapted as based on the reviewed literature. 3.4.2 Qualitative method In-depth interview guides were used to address issues around achievements and challenges of PSE and perceived impact of PSE thus addressing study objective number 2 and 3 respectively. For the purposes of this study, the 10 interviews were conducted in the respondent’s office. Interview guide had three parts where part A contained introduction to the interview, part B and C contained questions addressing the second and third objectives of the study, respectively. Part D of the interview guide collected data on the existence of any private sector engagement framework document(s). 3.5 Data Analysis The study adopted both descriptive and thematic content analysis techniques. The rationale for the adoption of these techniques was to descriptively articulate the role and extent of involvement of the private sector in provision of public health services towards universal health coverage in Kisii County. This included a description of the private sector engagement models employed, the achievements and challenges thereof as well as the health system managers’ perceptions on how effective private sector engagement has been in promoting universal health coverage in Kisii County. While descriptive analysis was employed on quantitative data in presentation of hard facts, thematic content analysis was conducted on qualitative data to enrich and complement the quantitative findings. 23 3.5.1 Quantitative data Data collected through the semi-structured questionnaires was analyzed using descriptive analysis which involved the use of frequencies in their absolute and relative forms (percentage) as well as means and standard deviations to measure central tendencies and dispersion respectively using Statistical Package for Social Sciences, version 25. 3.5.2 Qualitative Data Qualitative data collected through in-depth interview guides and review of existing engagement framework documents were edited for completeness, accuracy and consistency then coded to generate themes, patterns and relationships which are linked up with the study objectives using NVivo software, version 12. 3.6 Research Quality – Validity, Reliability and Objectivity of the Research 3.6.1 Validity Validity is the extent to which differences found with a measuring tool reflect true differences among respondents being tested (Ayodele, 2012) It can estimate the extent to which the data obtained accurately reflects the theoretical or conceptual concepts; that is if the measurements are consistent with the expectations. External validity was established by asking a series of questions, and often corroborated the answers in the research of others such as supervisors, statisticians and colleagues. Internal validity was ensured by focusing the questionnaires and interviews to the study objectives 3.6.2 Reliability Reliability refers to the accuracy and precision of a measurement procedure (Ayodele, 2012); measures the degree to which a research instrument gives consistent results. Reliability is concerned with estimates of the degree to which a measurement is free of random or unstable error (Ayodele, 2012). 3.6.3 Objectivity Objectivity in the study was assured through self-administration of the data collection instruments which were administered on a drop and pick method. Respondents were also directed before the data collection exercise to respond as honestly as possible to the best of their knowledge. 24 3.7 Ethical Consideration Prior to data collection, a clearance letter from the Strathmore University Ethical Review Committee and a research permit from the National Commission of Science, Technology and Innovation (NACOSTI) were obtained. These were then presented to the County Government during the introduction for permission to collect data. The researcher ensured only participants giving voluntary consent participated in the study. Informed consent was based on the information regarding: the purpose of the research study, identification of the researcher, any benefits that may be received. The researcher communicated this to the respondents before the start of the study. To avoid plagiarism, all works borrowed from other scholars are fully acknowledged. 25 Chapter 4 Results 4.1 Introduction This chapter presents findings from both the quantitative and qualitative data, their interpretation and discussions in relation to previous related empirical studies. The main analytical operations employed herein include the preliminary screening of data, descriptive analyses and thematic content analysis. 4.2 Response Rate The study achieved a 100.0% response rate with all the 52 participants targeted for questionnaires and 10 for interviews, reached. This is considered excellent by (Creswell, 2013) who postulates that a response rate of 50% is adequate for analysis and reporting; a rate of 60% is good and a response rate of 70% and over is excellent. The response rate can be attributed to the researcher- administered mode of data collection, as opposed to self-administration. The researcher would book a sit-down session with a respondent at their convenience, read the questions out to them and fill the responses in the questionnaire. It can also be attributed to follow-up phone calls made to interview respondents with a view to secure ample time for interviews in view of busy work schedules. 4.3 Respondent Demographic Characteristics This section describes the study participants’ demographic characteristics including respondent gender, respondent age, highest levels of education, level of management, as well as the nature of organizations respondents work for (Table 4.1). Table 4.1Distribution of Respondents by Gender Category Frequency (n) Percentage (%) Male 31 59.6 Female 21 40.4 Source: Survey Data, 2020 26 Age categories were also deemed a key factor in determining the age distribution among professionals in provision of public health services towards universal health coverage. The study established in this regard, as presented in Table 4.2, that a majority of study participants 53.8% were between the ages of 40-49 years while the least 1.9% was above 50 years. The finding implies that a majority of health professionals in provision of public health services towards universal health coverage in the study are middle aged. Table 4.2 Distribution of Respondents by Age Category Frequency (n) Percentage (%) 30-39 years 23 44.2 40-49 years 28 53.8 > 50 years 1 1.9 Source: Survey Data, 2020 The study further deemed respondents’ level of education a key indicator of the academic qualification among practitioners (Table 4.3). Most participants (67.3%) had attained undergraduate degrees, while 14 (26.9%) had a post-graduate degree. The least of the participants 3 (5.8%) were diploma holders. The finding is of the implication that a majority of professionals in the provision of public health services towards universal health coverage in the study area had relatively high academic qualifications, with most having at least an undergraduate degree. Table 4.3 Distribution of Respondents by Education Level Category Frequency (n) Percentage (%) Diploma 3 5.8 Basic degree 35 67.3 Post-graduate 14 26.9 Source: Survey Data, 2020 The study also deemed respondents’ level of management imperative in the administration of health systems and institutions charged with delivering universal health coverage in the country. Reaching participants at different levels of management was also aimed at assuring representativeness and diversity of experiential perspective with respect to administration of public health services towards universal health coverage. Table 4.4 indicates that out of 52 participants 55.8% of the respondents were middle level managers, 42.3% were senior managers 27 and 1.9% was a lower manager in the various positions in their respective organizations. It can be deduced that the study findings are representative of diverse managerial perspectives pertinent to administration of public health services towards universal health coverage. Table 4.4 Distribution of Respondents by Level of Management Category Frequency (n) Percent (%) Senior 22 42.3 Middle 29 55.8 Lower 1 1.9 Total 52 100.0 Source: Survey Data, 2020 Respondents were further asked to indicate whether they worked for government or private organizations. This was aimed at ensuring respondents from both the public and private sector entities pertinent to the provision of public health services towards universal health coverage are reached and represented. As tabulated in Table 4.5, a majority of respondents (59.6%) were proportionately drawn from private sector organizations while the remaining 40.4% were drawn from government institutions. It can thus be deduced that institutions from both the private and public sectors were reached. Table 4.5 Distribution of Respondents by Organization Category Frequency (n) Percent (%) Government 21 40.4 Private 31 59.6 Total 52 100.0 Source: Survey Data, 2020 4.4 Form of Private Sector Engagement with the County Government The study sought to determine the private sector engagement models used in Kisii County. To this end, respondents were asked to indicate the form of engagement existing between the county government and their respective organizations. As portrayed in Table 4.5, the majority of respondents (98.1%) affirmed to engaging with the county government through signing of memorandum of understanding while only1.9% affirmed to signing contracts. 28 Table 4.6 Form of Private Sector Engagement with the County Government Category Frequency (n) Percent (%) MOU 51 98.1 Contracts 1 1.9 Total 52 100.0 Source: Survey Data, 2020 The study further sought to establish the respective pillars that best describes the private sector engagement in relation to realizing universal health coverage. Options to this end included governance, human resource for health, financing, service delivery, health information systems and access to essential drugs and non-drug commodities. Table 4.7 presents findings in relation to governance pillar in the private sector engagement. From the table, only 28.8% of the respondents agreed that governance was the best pillar that describes private sector engagement while 71.2% dissented. Further, 94.2% agreed that service delivery best describes the pillar of private sector engagement while 5.8% disagreed. With regard to access to drugs and non-drugs as the best pillar to describe private sector engagement, a majority of the respondents (71.2%) dissented while only 28.8% agreed. A majority (51.9%) further disagreed that human resource pillar to describe private sector and county government engagement while 48.1% affirmed. A majority of respondents (53.8%) also dissented that health information pillar best described their private sector engagement while 46.2% affirmed. A majority (73.1%) however affirmed that health financing was the best pillar to describe the private sector engagement while 26.9% dissented. 29 Table 4.7 Pillars of Private Sector Engagement Yes No Pillar n % n % Governance 15 28.8 37 71.2 Service delivery 49 94.2 3 5.8 Access to drugs and non-drug commodities 15 28.8 37 71.2 Human resource 25 48.1 27 51.9 Health information system 24 46.2 28 53.8 Health financing 38 73.1 14 26.9 Source: Survey Data, 2020 Respondents were further asked to specify the private sector/government roles in the engagement. This was aimed at establishing the various stakeholder roles in the provision of public health services towards universal health coverage. It was established in this regard that the county government’s roles include provision of technical oversight to pertinent intervention projects and programmes; financial and human resource mobilization as per the MOUs and contracts; regulation of the private sector; provision of human resources; data review and provision of essential commodities and service delivery; assignment of roles; information dissemination; NHIF accreditation; administration and auditing; coordination and monitoring of activities; as well as training of staff and capacity building. The study further sought to determine the private sector engagement models entered between the private sector and the county government. As illustrated in Figure 4.1, a majority of respondents (96.2%) affirmed to Public-private partnership as best describing their private sector engagement models. This was distantly followed by 13.5% of respondents affirming to public-private mix and 11.5% either to financing or social marketing as best describing their private sector engagement models. Only 5.8% of respondents associated their model of engagement with either sector-wide approach or contracting out. 30 Figure 4.1Private Sector Engagement Models Source: Survey Data, 2020 Respondents were also asked to indicate the length of the private sector engagement with a view to determine the sustainability of the engagement models thereof as well as the length of experience with the respective models. As presented in Table 4.7, a majority of the respondents 40 (76.9%) have been in the private sector engagement for 3-5 years period while 12 (23.1%) of the respondent had 0-3 years private sector engagement experienced. Table 4.8 Length of Private Sector Engagement Frequency (n) Percent (%) 0-3 yrs 12 23.1 3-5 yrs 40 76.9 Total 52 100.0 Source: Survey Data, 2020 The study further sought to establish the legal framework anchoring the private sector engagement in order to find out the legislative framework underpinning private and public sector engagement in the provision of public health services towards universal health coverage. As illustrated in Figure 4.2, a majority of respondents (96.2%) strongly opted for Public-private partnership Act, 2013 as the ideal legal frame work that anchors private sector engagement with the county 13.5% 5.8% 5.8% 11.5% 11.5% 96.2% 0 20 40 60 80 100 120 Public-Private Mix Contracting-out Sector-wide Approach Social Marketing Financing Public-Private Partnership Percentage proportion M o d el o f En ga ge m en t 31 government of Kisii, while 13.5% opted for NGO Act, 2012 and 11.5% were of the opinion of public procurement & disposal Act, 2015 respectively. Figure 4.2 Legal Framework for Private and Public Sector Engagement Source: Survey Data, 2020 Respondents were further asked to indicate the frequency at which the Public-Private dialogue pertinent to the provision of public health services towards universal health coverage were held. As illustrated in Figure 4.3, a majority of the respondents (86.5%) held dialogue meetings on a quarterly basis, while 57.7% affirmed doing so bi-annually. A further 51.9% affirmed to annual dialogue while 48.1% affirmed to holding dialogue on a monthly basis. 96.20% 11.50% 13.50% 3.80% 88.50% 86.00% 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 120.00% Private-Private Partnership Act, 2013 Public Procurement & Disposal Act, 2015 NGO Act, 2012 Legal frameworks Yes No 32 Figure 4.3 Frequency of Public-Private Sector Dialogue Source: Survey Data, 2020 The study further sought to determine the purpose of the dialogue held with a view to determine the various areas of engagement. As Figure 4.4 illustrates, a majority of the respondents engaged the with the county government of Kisii during the planning (82.7%) and performance review (92.2%) periods, while 76.9% engaged the county during budgeting periods and the least being during policy issues. Figure 4.4 Areas of Engagement in Public-Private Sector Dialogue Source: Survey Data, 2020 51.9% 57.7% 86.5% 48.1% 0 10 20 30 40 50 60 70 80 90 100 Annually Bi-annually Quarterly Monthly P er ce n ta ge R es p o n se ( % ) Frequency Planning Budgeting Performance Review Policy Issues Yes 82.7 76.9 92.2 25 No 17.3 23.1 3.8 75 0 10 20 30 40 50 60 70 80 90 100 P er ce n ta R es p o n se 33 4.5 Perceived achievements and Challenges in Engaging the Private Sector The study sought to explore the achievements and challenges the Kisii County government faces in engaging the private sector. To this end, interview respondents were first asked to describe the private sector engagement’s contribution in realizing universal health care in Kisii County. Overall, majority of respondents observed that private sector engagement had contributed towards the realization of UHC in their respective areas. Engagement achievements mentioned included the private sector provision of human resource to supplement the understaffed public health facilities; technical and capacity building support, provision of commodity supplies; training of community health volunteers; technological support through digitalization of otherwise paper based data collection and reporting; financial support through payment of stipends to community health volunteers and financing of projects and/or programme activities aimed at UHC. The other achievement mentioned was provision of healthcare services through private facilities. “……..The private sector has contributed in many aspects towards realizing universal health coverage in Kisii county for instance, technical and financial support. They also supplement the staff that are employed by Kisii county by providing human resource which is a critical arm in achieving universal health coverage ……… ” Public Sector Provider II “…We have been able to support some of the interventions by the county government at the community level. We have built capacity of community health volunteers to enable them diagnose and manage basic healthcare conditions at the community level and refer cases that they are not able to manage…. We have empowered the community health volunteers with smartphones for access to data and information sharing… ” Private Sector Provider I The study also sought to understand challenges faced by the county government in public private engagement. A key challenge identified was difficulty in regulating and holding accountable the 34 private sector, as they had leeway to choose activities to engage in. Other challenges mentioned included difficulty engaging the private sector in less profitable initiatives such as HIV prevention campaigns; inability of the county to sustain programmes initiated by the private sector; supply chain gaps, mainly touching on commodities; insufficient financing of health services and activities; and non-disclosure of data to enable the county government develop and improve its indicators. Interview informants for instance intimated that: “………Private sector is very difficult to regulate. though they support our activities, we don’t regulate. most of the activities they do are per their own activities……….” Public Sector Provider II “…………..We also have commodity issues. when these community health volunteers are capacity built, they are supposed to management common ailment but they are not able to due to intermittent supply of commodities, there is a supply chain gap in that at times when they are required to be supplied on a quarterly basis, it happens semi- annually and therefore they go a full quarter with no sufficient amounts of essential commodities to support at the level……. Finances are also a challenge………. At least 15% is supposed to be allocated for health which is not adhered so there is a lot of underfunding of activities aimed at realizing universal health coverage……….” Public Sector Provider VI Respondents were further asked how the challenges could be addressed. Majority proposed increasing public health financing at both the national and county government level. Another proposal was for the county government to lead the process of developing joint plans with the private sector that include UHC priority activities, thereby making better use of private sector resources and support. Interviewees advised that robust capacity building of healthcare workers was needed to make the engagement activities more sustainable and with higher impact. It was further suggested that in order to address the supply chain challenges, particularly delays in supply of commodities, the 35 county government should be given the mandate by the national government to procure and supply commodities. A feedback from the interview respondents is as displayed below: “………..As a county, we should be able to have some control over some of the private sector actors because at times you have all of them supporting one area. We should be able as a county to consider our areas of interest, and propose areas of support for the private sector to chip in………..” Public Sector Provider VI 4.6 Manager Perceptions on the Impact of Private Sector Engagement The study sought to explore health system managers’ perceptions on the impact of private sector engagement in promoting progress towards UHC in Kisii County. To this end, respondents were asked to indicate how the healthcare system in Kisii County benefit from private sector engagement along six key thematic areas, including system governance, improved health work force, health financing, access to quality health services and health seeking behaviors, improved technology and access to quality drugs. 4.6.1 System Governance The study sought to find out whether or not in respondents’ opinion, system governance had benefited from private sector engagement. A majority of respondents observed that engagement had improved health system governance. More specifically, existing memoranda of understanding had resulted in improved alignment of purpose by catering for the interest of both the public and private sectors, clearly stipulating the terms of engagement, accountability structures and transparency measures. Further, the private sector was engaged in quarterly stakeholder meetings for purposes of planning, performance reviews, and budgeting which has led to strengthening of governance systems. Resource mobilization had also improved with the engagement of the private sector as they contribute both human and financial resources to programmes and activities towards universal health coverage. An interview informant noted that: 36 “……..System governance is much better off now with the engagement of the private sector. We had been experiencing improved financial resource allocation from the donors because of more transparency and accountability in monies which were channeled through the private sector. As opposed to early 2000s when donor funds dwindled due to lack of accountability, with engagement with the private sector, the accountability has improved as it is now more of a resource-based funding whereby money is given as need arises instead of giving money first and they accounting later……….” Public Sector Provider II 4.6.2 Improved Health Work Force Similarly, interviewees recognized the role of engagement in strengthening health workforce. It was noted that the private sector had contributed by recruiting staff at the county government and community levels but are remunerated by the private sector, which significantly bridges the human resource gaps at the county government as a result of attrition and low employment rates. The private sector also contributes by training of staff, capacity building and by boosting staff capacity of nurses and clinical officers, as well as by provision of lay workers, for instance mentor mothers, PIA navigators and adherence counselors who run various key the programs such as HIV/AIDS campaigns, contact tracing, appointment bookings among others. “…Private sector employs a good number of healthcare providers for the public sector under their payroll. They contribute to paying stipends to community health volunteers which is the primary health level for the sub county…” Public Sector Provider III “……..We recruit, retain and build capacity of staff at the community level to bridge the gap by the county government in various interventions. We also empower the staff at community level by giving them mobile technology for clerking of clients and referrals ……….” 37 Private Sector Provider II 4.6.3 Health Financing The study further established that the private sector has significantly improved health financing, bridging the inadequate budgetary allocation for heath at the county government, through financing of various activities and programmes aimed at realizing the universal health coverage, recruitment and payment of staff. A few challenges were however noted in health financing, including non-allocation of funds to pertinent areas in the realization of universal health coverage, such as community sensitization and development of relevant robust community initiatives. Some of the response are as follows: “……..The budget from the government for health is not adequate. The private sector helps bridge the gap, for instance, payment of the staff they recruit, easing public facilities……..” Public Sector Provider IV 4.6.3.1 Access to Quality Health Services and Health Seeking Behaviors The study further established that private sector engagement has greatly improved access to quality health services and health seeking behaviors, through among other ways, recruiting, training and empowering community health volunteers to be able to diagnose, treat and refer cases, as well sensitize the communities on the importance of seeking health services and in good time. Some have specialized in special groups, such as adolescents, people living with HIV/AIDS and expectant mothers, empowering them on how to, when and where to seek health services. A response is as presented below: “………Most of the mothers now are able to deliver in maternity hospitals due to sensitization on the part of the private sector … They have also helped in training healthcare providers with a view to improve the quality of services……….” Public Sector Provider VI 38 4.6.5 Improved Technology It was also established that the private sector has led to improvements in technology through the development of health management information systems, which has enhanced the decision- making process at the county government as well as efficiency of operations through digitization of various administrative services, data collection, data aggregation, computation and information sharing hence improved service delivery. The private sector has also developed community-based applications which have helped community health volunteers improve healthcare at the lowest level in the long run through providing real time data for effective and timely decision making. Health facilities also use electronic medical records which run on systems developed by and supported by the private sector. Some of the responses to this effect are hereunder provided: “……..The private sector has revolutionized has we used to delivery healthcare services…... Back then, it used to be heavily paper based but now we have systems installed and computers which has improved service delivery. Living Goods for instance have an app that community health volunteers use and for contact and defaulter tracing and reporting………” Public Sector Provider II “….We have supported the county in improved technology in terms of attending to patients, systems of follow ups referrals, access to quality data. Initially, data at the community level was paper based but we have been able to digitize reporting tools making it easier for anyone to access data at any point in time. This has reduced the turnaround time in terms of reporting at the community level since whoever is supposed to collate does not have to wait for hardcopy data……We have a dashboard that can be accessed by everybody including supervisors who are able to monitor the information for prioritized supervision…” Private Sector Provider III 39 4.6.6 Access to Quality Drugs Private sector engagement has further led to the improvement in access to quality drugs through standardizing the quality of drugs and availing donor funded drugs such as for Tuberculosis, Malaria, cancer treatment drugs and Antiretroviral for HIV treatment which are scarcely available in government facilities. Further, the private sector has been instrumental in supplementing commodity stock outs and supplying community health volunteers with quality drugs which has led to reduction in mortality and morbidities previously experienced. An interviewee for instance offered that: “……….We have been able to ensure the drugs offered at the community level are standardized by taking them through the normal standardization test that is checking their effectiveness and efficiency based on the disease conditions they are supposed to be treating and so we have been able to get certification on a yearly basis. Additionally, we are only able to procure commodities from outlets identified and approved by the government…………” Public Sector Provider VII 4.7 Existence of Engagement Framework The study finally sought to establish whether there existed a legal and/or strategic framework that guided recruitment of private sector players into the system. It was established in this regard that the main legislative documents underpinning the county government’s engagement with the private sector included the Public Private Partnership Act, a Partner Coordination Framework and memoranda of understanding with individual private sector partners outlining the various parties’ individual and joint responsibilities. This was echoed by all interview respondents: “……We have an MOU that includes resource sharing resources for example finances and human resources……..” Public Sector Provider V 40 “…….We have an MOU that guides the implementation of interventions between us and the county. It has several guidelines in terms of areas of improvement, roles and responsibilities of different parties………” Private Sector Provider IV 41 Chapter 5 Discussion 5.1 Introduction This chapter presents a summary of key findings and draws conclusions based on the research findings. Recommendations are further provided for practice and policy, as well as suggestions for future studies informed by the present study limitations. 5.2 Summary of Key Findings The study sought to determine the private sector engagement models used in Kisii County. A majority of respondents (98.1%) affirmed to engaging with the county government through signing of memorandum of understanding while only1.9% affirmed to signing contracts. The study also sought to establish the respective pillars that best describes the private sector engagement in relation to realizing universal health coverage. A majority of respondents affirmed that service delivery (94.2%) and health financing (73.1%) were the pillars that best describe their private sector engagement. The study further sought to determine the private sector engagement models entered between the private sector and the county government. It was found that a majority of respondents (96.2%) affirm to public-private partnership as best describing their private sector engagement models. A majority of respondents (96.2%) further strongly opted for Public-private partnership Act, 2013 as the ideal legal framework that anchors private sector engagement with the county government of Kisii, The study also sought to explore the achievements and challenges the Kisii County government faces in engaging the private sector using the identified models. It was established that among the achievements include the private sector provision of human resource to supplement the understaffed public sector particularly in public health facilities; technical and capacity building support; technological support; and financial support. Among the main challenges identified with private sector engagement include difficulty in regulating and holding accountable the private sector. The study further sought to explore health system managers’ perceptions on the impact of private sector engagement in promoting progress towards UHC in Kisii County. A majority of 42 respondents affirmed that system governance has improved with the engagement of the private sector through mission alignment between the public and private sector. It was particularly noted that the private sector has contributed by recruiting staff at the county government and community levels but are remunerated by the private sector, which significantly bridges the human resource gaps at the county government. 5.3 Discussion of Results It can be deduced from the foregoing findings that there exist formal arrangements between public and private sector actors in provision of public health services towards universal health coverage, and that a majority of private sector actors adopt MOUs as opposed to contracts in their engagements with the county government. This is tandem with Maluka et al. (2018) who observe that in the context of universal health coverage, formal engagement with private sector providers is an imperative strategy in a majority of middle—and-low-income countries for extending coverage of publicly financed health services. This is also in agreement with Grieve and Olivier (2018) who assert that formal engagement between private and public sector organizations in the provision of public health services is beneficial since upon availing public funds to the private sector formally, it reduces the private sector’s need to attempt to raise funds through high user fees. Further, such formal arrangements help establish quality standards for private sector health services and increasing accountability thereof. It can also be deduced from the findings that service delivery and health financing best describe the pillar of private sector engagement. This is in line with (Blumenthal & Hsiao, 2015) who observe that service delivery is a direct output of the health system inputs including financing, the health workforce, supplies and procurement, and that increasing inputs would directly translate into enhanced access to services and improved service delivery. The service delivery pillar secures access to and ensures availability of public health services meeting a minimum quality standard which are major health systems’ functions. The finding is also in agreement with (Stallworthy et al., 2014) who argued that health financing is critical in health systems’ ability to improve and maintain human welfare. Without the requisite finances at the extreme, medicines would not be available, health workers would not be employed, and health prevention or promotion would not take place. 43 The findings are further of the implication that the role of the county government in their engagement with the private sector towards realizing universal health coverage is largely supervisory, resource mobilization, administration, monitoring and coordination as well as service delivery. The finding is consistent with Achoki, Miller-Petrie, Glenn, Kalra, Lesego and Gathecha (2019) who found that the county governments have a central role to play in targeting and identifying households for NHIF enrolment and that national governments ought to avail financial resources to facilitate increased population coverage through the NHIF in keeping with universal health coverage. It is also implied from the findings that whereas a myriad of private sector engagement models is employed in the study area, Public-private partnership is the most popular. Accordingly, (Garvin & Bosso, 2008) and (Hackworth, 2019) attribute the rise of PPPs worldwide to its characteristic high level of engagement, risk transferring/ sharing between the parties, long-term contractual obligations ranging to up to 30 years and highly capital intensive. Gaffney, Pollock, Price, & Shaoul (1999) are in agreement that PPPs owe their popularity to their operational diversity which include concession contracts, joint ventures, Rehabilitate Operate Transfer (ROT) contracts and Build Operate Transfer (BOT) type contracts among others. The findings agree with (Nabyonga-Orem, Nabukalu, & Okuonzi, 2019) who studied partnership with private for-profit sector for universal health coverage in sub-Saharan Africa with a focus on opportunities and caveats. Results from the study showed that public–private partnership in health exist in several forms including strategic partnerships bound by a memorandum of understanding (MOU) between the different parties. The study also showed that in some countries, contractual arrangements bound by a legal contract have been attempted although the capacity to negotiate and monitor contracts in LIC is weak. Similarly, Whyle and Olivier (2016) reported in their systematic review of models of public– private engagement for health services delivery and financing in Southern Africa, that 52 individual public–private partnership in health initiatives in Southern Africa. These initiatives represent eight distinct public–private partnership in health models, including social marketing, sector-wide approach, contracting out, voucher programmes, public–private mix approach, regulation, financing and public–private partnership. 44 The results however contrast Hung, Klinton and Eldridge (2020) whose study assessed the level of private health sector engagement in 18 low- and middle-income countries (LMICs) with highest overall utilization of private health providers in six WHO regions. Findings from the study indicated a general recognition of private health sector’s role in achieving population health goals, but specific policies on private sector engagement remained uncommon. The study further deduces from the findings, that public and private sector engagement towards realizing universal health coverage have been in place for over 3 years, indicate sustainability in the short term, and therefore a prospect for the long term. A