UHC is a national priority for Kenya. In 2018, it was selected to be part of Kenya’s ‘Big 4 Agenda’, the country’s top four priorities for socio-economic transformation. The country of approximately 47.6 million people (per 2019 Census) has prioritized PHC as a critical pathway for achieving UHC and allocates as much as 57% of its health budget to PHC.1 In 2020, the country launched the PHC strategic framework based on the existing Health Policy (2014-2030) and the country’s UHC roadmap to guide PHC implementation. The framework seeks to ensure that quality PHC services are equitably available to the populace. The country intends to achieve this by organizing PHC service delivery around a network of community and PHC facilities modelled as Primary Care Networks (PCNs). However, two years after the launch of the strategic framework, the country had yet to initiate implementation. When the COVID-19 pandemic began and further widened existing inequities in service coverage and quality, it became even more imperative to ensure quality health service were within reach. As a result, Kenya set out in 2020 to pilot PCNs, as stipulated in the PHC framework, to demonstrate the effectiveness of the approach and to utilize learnings from the process to inform the scale up of PCNs in the country.
The Implementation Case
Kenya Learning Questions
- What are some effective approaches to secure buy-in of county-level leadership
- How can we ensure there is quality of care within PCNs?
- How can we adapt the implementation process given the constraints resulting from the COVID-19 pandemic?
Dissemination of Guidelines: How do we promote adherence to the guidelines?
- How can the effectiveness of implementation be best measured?
- What enablers or barriers could affect the M&E process?
Knowledge Sharing: How can we facilitate knowledge sharing to support PCN operationalization across the entire country?
- How can we overcome the threat of inadequate resource allocation to support implementation?
- How can we support counties to mobilize resources to support implementation?
- What is the most appropriate communication setup that would include feedback and support improvements across all tiers/levels of service delivery within networks?
- What are some effective advocacy strategies for key stakeholders including health providers and the communities?
The team leading the government-owned pilot project to operationalize PCNs—technical staff and leaders from Kenya’s Ministry of Health—became the Implementation Case team and embedded their work within this Learning Exchange.
The team had an audacious vision: all Kenyans will have access to affordable quality PHC services closest to where they are. Based on this, the technical facilitation team supported the Implementation Case team to outline the existing challenge as follows:
PHC facilities in Kenya fail to collectively offer a comprehensive range of services that are responsive to the needs of communities within their catchment area; in some instances, about 50% of Kenyans bypassed health facilities closest to them in search of quality care, and this led to increased cost of care and poorer outcomes. This was because PHC facilities lacked effective linkages between facilities on the same tier and across tiers within the same communities, a problem that could be solved through the establishment of functional PCNs. Although the National PHC strategy recommended establishing PCNs, this was impeded by inadequate resource allocation and limited knowledge (especially at the county-level implementation).
The Implementation Case team then conducted the causal chain analysis, the series of steps and events to lead to the identified outcomes, which they later described as one of the most useful activities because it clarified what they needed to do to be successful. Based on the causal chain analysis, the Implementation Case team developed corresponding goals and expected outcomes and an implementation plan. The goals formed the signposts for implementation:
- Establish PCNs in five counties.
- Develop and disseminate implementation guidelines to all implementing counties.
- Develop monitoring and evaluation (M&E) mechanisms for measuring the effectiveness of the PCNs.
- Document and share implementation lessons with relevant stakeholders.
Collaborative Learning Process
From the outset, the Implementation Case team and the technical facilitators co-created a learning agenda to guide the collaborative learning process. The questions that formed the agenda were clustered in six thematic areas including implementation, M&E, financing, and advocacy (See Kenya learning questions).
Since the aim was to learn together as Kenya implemented the case, the Implementation Case team participated in monthly check-in meetings with the facilitation team and peer learners, where they shared their questions and challenges and provided progress updates. Peer learners had the opportunity to ask questions about the implementation experience, share relevant experiences and ideas on how to overcome the challenges, and to address the Implementation Case team’s questions. In addition to guiding the discussions during the check-ins, the facilitation team mapped emerging linkages with the pre-defined learning agenda and shared relevant resources and tools to support implementation. The Implementation Case team also received technical support; for instance, the peer learners and the technical facilitators reviewed and provided inputs on the baseline evaluation. The Learning Exchange also provided the Implementation Case team with an accountability mechanism – they had to share key activities and objectives for the following month and report on these at the next monthly check-in.
Despite the disruptions in timelines and resource constraints within selected counties due to COVID-19, implementation progressed to varying extents within selected counties. Two counties, Kisumu and Garissa, started full implementation while only sensitization (the inception activity) occurred in five additional counties (Mombasa, Makueni, Nakuru, Kakamega, and Marsabit). The PCN guidelines have since been finalized, launched, and virtually disseminated to a countrywide audience. An M&E tool—with considerable measures from the country’s PHC Vital Signs Profile—was developed and a baseline evaluation was conducted for five counties. Armed with insights on resource mobilization, advocacy, and strategic communication and experiences from members of the Learning Exchange, the Implementation Case team was able to secure funding to scale up the PCNs to seven additional counties. They were able to secure the buy-in of the county leaders—which was a key issue on the learning agenda—and the county-level decisionmakers joined some sessions of the Learning Exchange. One of the counties, Kisumu, started a process to document its learnings for sharing with other counties. The PCNs are already demonstrating their potential to improve health outcomes in Kenya. For instance, Garissa, one of the pilot counties, has seen an improvement in its referral systems and in key health indicators such as maternal mortality.
Key Lessons and Insights
The process gave the Kenya Implementation Case team valuable insights on PCN design and implementation stages including planning, actual implementation, and evaluation. Both the Implementation Case team and other participants benefitted immensely from the rich lessons provided through the actual implementation, the learning checks and virtual exchanges, the technical support by facilitators and resource persons, and the existing tools and resources that were shared. The approach of using causal chains that make use of both quantitative and qualitative evidence to break down the challenges into actionable components proved to be most useful to the Implementation Case team.
This case also demonstrated the additional value in ensuring the team composition supports the values of the learning community and its approach. The Implementation Case team was able to ensure the learning agenda was country-led and relevant to their work as the leads in policy and program management. Also, because the team had the requisite mandate at the country level, they were able to bring on board subnational actors with relative ease.
Finally, the learning process also underscored practical and significant lessons on how to operationalize PCNs. Here are four key lessons on operationalizing PCNs identified within the Learning Exchange:
- Be inclusive during design. A decentralized approach was critical to the success of implementation, especially because of the devolved governance structures in Kenya. More generally, because sub-national actors drive implementation, it is critical to include the sub-national leaders during the design and planning phases of such a project. One challenge the team faced was that the PCNs were not budgeted for within the counties’ annual workplans because the team missed the counties’ planning cycle. Some counties also needed to alter aspects of the PCN design to accommodate their unique circumstances and makeup of existing health facilities. Thus, the Implementation Case team recognized it was necessary to have county specific, tailored PCNs. By including sub-national government actors in the design and planning and being flexible, it allowed for co-creation of PCNs that were responsive to the needs of the counties.
- Be adaptable. The considerable disruptions to implementation caused by COVID-19 (restrictions and shortfall in both workforce and material resources) required implementers to adapt and to try alternative recommendations from the technical facilitators and peer learners. For instance, peer learners advised the implementation team to replace traditional in-person meetings with online/hybrid meetings and to disseminate the guidelines at the county level rather than the national level as planned. Peer learners advised the Implementation Case team to engage regional- and county-level partners in smaller meetings whenever the national team was unable to travel due to COVID-19 restrictions. The Implementation Case team needed to be flexible to assess and implement innovative, alternate approaches.
- Build alliances proactively. Successful implementation required proactive identification and nurturing of alliances to advance efforts. For instance, during implementation, the Implementation Case team identified that a change in political leadership would be a risk to the project. Based on their own experiences, the peer learners and technical facilitators suggested this could be mitigated by first forming alliances with CSOs and partners then identifying champions for PCNs. The Implementation Case team initiated several such advocacy efforts, including opportunistic usage of other platforms such as the intergovernmental forum, to advocate for PCNs.
- Align interventions with policies. When a project or activity has a basis in an existing policy, strategy, or programs, it facilitates successful implementation. In this case, because the PCNs were captured in the country’s PHC strategic plan, it was possible to mobilize resources for the project and make a case for counties to invest in it too.
PCN implementation will continue in Kenya. Based on the first-hand learning provided through the Learning Exchange, the Implementation Case team plans to start a similar learning platform for the counties. The Implementation Case team has also developed an advocacy, communication, and engagement framework that draws from the JLN Strategic Communications and Advocacy Tool to guide PHC/PCN implementation. Additionally, the Implementation Case team acknowledged that the issue of ensuring that PCNs have the requisite skill mix and number of health workers was sub-optimally addressed in this phase of implementation. They intend to prioritize workforce-related issues in the next phase of implementation.
Drawing from lessons learned on resource mobilization and strategic communication, Kenya will continue to court partners and other stakeholders to support implementation. In the coming months, the country will step up its efforts to measure the effectiveness and implementation of the PCNs, ensuring that the measures are robust, reflective of the county-level performance, and that the process is automated. Regarding the collaborative learning aspects of this engagement, the Implementation Case team appreciated the process but had hoped for more opportunities for cross country experiential learning, including in-person interactions when feasible.
The disruption to health service delivery caused by COVID-19 made it more imperative to ensure that regardless of who a person is, what they do, or where they find themselves, they can access affordable quality PHC services. Despite the resource constraints induced by COVID, Kenya was able to pilot the PCNs in seven counties. These efforts are expected to continue and be scaled up to additional counties. The team anticipates that the PCN implementation and its outcomes will be effectively measured, and lessons shared to inform further adaptations and scale up. In all, the Implementation Case team found the collaborative learning process useful because of the use of causal links, the opportunity provided to learn from peers, and the community support for implementation.
The Learning Exchange would also like to thank the entire Kenyan Implementation Case team, particularly Dr. Agatha Olago and Dr. Helen Kiarie, the co-leads of the case. We would also like to thank Victor Achieng, Damiano Stellar, Nii Sarpei, and Ali Walimbwa who provided useful insights to support the implementation team as peer learners.
The Implementation Case teams were supported by technical facilitators: Dr Leizel Lagrada-Rombaua, Dr. Belinda Nimako, Muchiri Nyaggah, and Dr. Luis Gabriel Bernal Pulido. Linda Arogundade, Dany Chhan, Amanda Folsom, Chloe Lanzara, Tania Mathurin, and Emma Stewart at R4D provided technical and operational support to the teams. The development of this Learning Exchange was supported with funding from the Bill & Melinda Gates Foundation.
1. Find additional data on Kenya’s PHC system on the Kenya Vital Signs Profile.