1. BCM 425: Applications of Community
Health- Lecture 2
The organization and structure of health care
delivery systems
2. Background
Health in Kenya
• Tropical diseases, especially malaria and
tuberculosis, have long been a public health
problem in Kenya.
• In recent years, infection with the Human
Immunodeficiency Virus (HIV), which causes
acquired immune deficiency syndrome (AIDS),
also has become a severe problem(Estimates of
the incidence of infection differ widely).
• And noe COVID 19
3. Background…
• The life expectancy in Kenya in 2016 was 69.0
for females and 64.7 for males. This has been an
increment from the year 1990 when the life
expectancy was 62.6 and 59.0 respectively.
• The leading cause of mortality in Kenya in the
year 2016 included diarrhoea diseases 18.5%,
HIV/AIDs 15.56%, lower respiratory infections
8.62%, tuberculosis 3.69%, ischemic heart disease
3.99%, road injuries 1.47%, interpersonal
violence 1.36%.
4. Background…
• The burden of disease in Kenya has mainly
been from communicable diseases but it is
now shifting to also include the
noncommunicable diseases and injuries.
• As of 2016, the 3 leading causes of death
globally were ischemic heart disease 17.33%,
stroke 10.11% and chronic obstructive
pulmonary disease 5.36% .
5. What is a health system?
• A health system, also sometimes referred to as
health care system, is the organization of
people, institutions, and resources that deliver
health care services to meet the health needs of
target populations.
• There is a wide variety of health systems
around the world, with as many histories and
organizational structures as there are nations.
Implicitly, nations must design and develop
health systems in accordance with their
needs and resources, although common
elements in virtually all health systems are
primary healthcare and public health
measures.
6. • The World Health Organization defines health
systems as follows:
A health system consists of all
organizations, people and actions whose
primary intent is to promote, restore or
maintain health. This includes efforts to
influence determinants of health as well as
more direct health-improving activities.
7. • A health system is therefore more than the
pyramid of publicly owned facilities that
deliver personal health services. ..It includes,
for example, a mother caring for a sick child
at home; private providers; behaviour change
programmes; vector-control campaigns;
health insurance organizations; occupational
health and safety legislation. It includes inter-
sectoral action by health staff, for example,
encouraging the ministry of education to
promote female education, a well known
determinant of better health.
8. • In some countries, health system planning is
distributed among market participants. In
others, there is a concerted effort among
governments, trade unions, charities, religious
organizations, or other co-ordinated bodies to
deliver planned health care services targeted to
the populations they serve. However, health
care planning has been described as often
evolutionary rather than revolutionary.
9. Health care system structure
• Most countries structure the delivery of
government provided health services as a
hierarchy –from small peripheral units (‘sub-
centers’ or health posts) to larger clinics, small
hospitals, and larger hospitals.
• The lowest level facilities are most accessible and
lower in cost but also have the most limited
scope of services and are least demanding in
terms of quality. In contrast, large hospitals are
the least accessible and most costly, but offer a
wide scope of services and are the most
demanding in terms of quality.
10. Health care system structure ctd..
• The structures of health care systems helps
determine how doctors and nurses collaborate
during patient mx. A greater understanding of
such team-based treatment in hospitals could
help improve patient care.
• Collaboration among different types of health
care professionals, is good for patients because it
provides greater communication, coordination of
care and patient-centered decision making.
11. Health care system(Kenyan context)
• The health sector comprises the public system, with
major players including the MOH and parastatal
organisations, and the private sector, which includes
private for-profit, NGO, and FBO facilities.
• Health services are provided through a network of
over 4,700 health facilities countrywide, with the
public sector system accounting for about 51 percent
of these facilities.
• The public health system consists of the following
levels of health facilities: national referral
hospitals, provincial general hospitals, district
hospitals, health centres, and dispensaries.
12. MoH: Levels of Service Delivery..
National Health Sector Strategic plan
II (2006-2010)
• Level 1– Community
• Level 2 – Dispensaries
• Level 3 – Health centers
• Level 4 –District/county referral hospitals (47)
• Level 5 – Provincial referral hospitals (10)
• Level 6 – National referral hospitals (2)
13.
14. Health care system(Kenyan context)
ctd..
• National referral hospitals are at the apex of
the health care system, providing
sophisticated diagnostic, therapeutic, and
rehabilitative services. The two national
referral hospitals are Kenyatta National
Hospital in Nairobi and Moi Referral and
Teaching Hospital in Eldoret. The equivalent
private referral hospitals are Nairobi Hospital
and Aga Khan Hospital in Nairobi.
15. Health care system(Kenyan context)
ctd..
• Provincial hospitals act as referral hospitals to their
district hospitals. They also provide very specialized
care. The provincial level acts as an intermediary
between the national central level and the districts.
• They oversee the implementation of health policy
at the district level, maintain quality standards, and
coordinate and control all district health activities.
• Similar private hospitals at the provincial level
include Aga Khan Hospitals in Kisumu and
Mombasa.
16. Health care system(Kenyan context)
ctd..
• District hospitals concentrate on the delivery of
health care services and generate their own
expenditure plans and budget requirements based
on guidelines from headquarters through the
provinces.
• The network of health centres provides many of
the ambulatory health services. Health centres
generally offer preventive and curative services,
mostly adapted to local needs.
17. Health care system(Kenyan context)
ctd..
• Dispensaries are meant to be the system’s first line of
contact with patients, but in some areas, health
centres or even hospitals are effectively the first
points of contact.
• Dispensaries provide wider coverage for preventive
health measures, which is a primary goal of the health
policy.
• The government health service is supplemented by
privately owned and operated hospitals and clinics
and faith-based organisations’ hospitals and clinics,
which together provide between 30 and 40 percent of
the hospital beds in Kenya.
18. Health care system(Kenyan context)
• Kenya’s health care system is structured in a step-
wise manner so that complicated cases are
referred to a higher level. Gaps in the system are
filled by private and church run units.
• Dispensaries and private clinics
• Health centres
• Sub-district hospitals and nursing homes
• District hospital and private hospitals
• Provincial hospital
• National hospital
19. Dispensaries
• The dispensaries are at the lowest level of the
public health system and are the first point of
contact with patients.
• They are staffed by enrolled nurses, public health
technicians, and medical assistants.
• The enrolled nurses provide antenatal care and
treatment for simple medical problems during
pregnancy such as anaemia, and occasionally
conduct normal deliveries.
• Enrolled nurses also provide basic outpatient
curative care.
20. Health Centres
• Health centres are staffed by midwives or nurses,
clinical officers, and occasionally by doctors. They
provide a wider range of services, such as basic
curative and preventive services for adults and
children, as well as reproductive health services.
• They also provide minor surgical services such as
incision and drainage.
• They augment their service coverage with outreach
services, and refer severe and complicated
conditions to the appropriate level, such as the
district hospital.
21. District Hospitals
• District hospitals are the facilities for clinical
care at the district level. They are the first
referral hospital and form an integral part of
the district health system. They should
provide
• Curative and preventive care and promotion
of health of the people in the district;
• Quality clinical care by a more skilled and
competent staff than those of the health
centres and dispensaries; Treatment
techniques such as surgery not available at
health centres;
22. District Hospitals ctd..
• Laboratory and other diagnostic techniques
appropriate to the medical, surgical, and
outpatient activities of the district hospital;
• Inpatient care until the patient can go home or
back to the health centre;
• Training and technical supervision to health
centres, as well as resource centre for health
centres at each district hospital;
• Twenty-four hour services;
• The following clinical services(Obstetrics and
gynecology; Child health; Medicine; Surgery,
including anaesthesia)
• Accident and emergency services
23. District Hospitals ctd..
• Non-clinical support services;
• Referral services;
• Contribution to the district-wide
information generation, collection
planning, implementation and
evaluation of health service
programmes.
24. Provincial Hospitals
• Provincial hospitals form a secondary level of
health care for their location. They provide
services to a geographically well-defined area.
• They provide specialized care, involving skills
and competence not available at district hospitals,
which makes them the next level of referral after
district hospitals.
• Their personnel include medical professionals,
such as general surgeons, general medical
physicians, paediatricians, general and
specialized nurses, midwives, and public health
staff.
25. Provincial Hospitals ctd..
• Provincial hospitals should provide clinical
services in the following disciplines: ..
Medicine; General surgery and anaesthesia;
Paediatrics; Obstetrics and gynaecology;
Dental services; Psychiatry; Accident and
emergency services; Ear, nose and throat;
Ophthalmology; Dermatology; ICU (intensive
care unit) and HDU (high dependency unit)
services.
26. Provincial Hospitals ctd..
They should also provide the following services:
• Laboratory and diagnostic techniques for referrals
from the lower levels of the health care system;
• Teaching and training for health care personnel
such as nurses and medical officer interns;
• Supervision and monitoring of district hospital
activities;
• Technical support to district hospitals such as
specific outreach services.
27. Teaching and Referral Hospitals
• They are centres of excellence and provide
complex health care requiring more complex
technology and highly skilled personnel.
• They have a high concentration of resources
and are relatively expensive to run.
• They also support the training of health workers
at both pre-service and in-service levels.
28. Teaching and Referral
Hospitals(functions)
Health care.
• Referral hospitals provide complex curative tertiary
care. They also provide preventive care and
participate in public health programmes for the local
community and the total primary health care system.
• Referrals from the districts and provinces are
ultimately received and managed at the referral
hospitals.
• The referral hospitals have a specific role in
providing information on various health problems
and diseases.
29. Teaching and Referral
Hospitals(functions)
• They provide extra-mural treatment alternatives
to hospitalisation, such as day surgery, home care,
home hospitalisation and outreach services
Quality of care.
• Teaching hospitals should provide leadership in
setting high clinical standards and treatment
protocols.
• The best quality of care in the country should be
found at teaching and referral hospitals.
30. Teaching and Referral
Hospitals(functions)
Access to care.
• Patients may only have access to tertiary care
through a well-developed referral system.
Research.
• With their concentration of resources and
personnel, teaching and referral hospitals contribute
in providing solutions to local and national health
problems through research, as well as contributing
to policy formulation.
31. Teaching and Referral
Hospitals(functions)
Teaching and training.
• Teaching is one of the primary functions of these
hospitals. They provide both basic and post-
graduate training for health professionals.
32. Organization of health systems…
• Health systems are organized into different
forms in different countries.
• Health systems are organized based on
government and administrative levels.
33. Role of MoH in service delivery
1.Curative Services
Responsible for service delivery at:
• Level 6 – National referral hospital
• Level 5 – Provincial referral hospital
• Level 4 – District & Sub-district referral
hospital
34. Role of MoH in service delivery
2.Health Promotion & Prevention
Responsible for service delivery at:
• Level 3 – Health centre
• Level 2 – Dispensary
• Level 1 – Community
35. Roles of Kenya Health System Actors
• MoH national level: formulate health policy; develop
health strategic plan; coordinate partners, mobilize
resources and build capacity
• Public sector facilities: provide health services to the
population
• Private and faith-based institutions: deliver services
and build capacity to complement GoK
• Alternative medicine practitioners: offer alternative
medicine services
• Facility leadership, governance and advocacy
• Development partners: mobilize resources and
provide technical assistance
36. Devolved heath care in Kenya
In 2010, Kenyans overwhelmingly voted in the new
constitution.
One of the major changes that came with this was the
change in the form of governance from the central
governance system to the devolved system.
Healthcare was one of the major sectors that was
devolved. Devolution of health services meant that
county governments are entrusted with all functions
related to health care while the national government
is responsible for health policy and national referral
health facilities.
37. Kenya constitution 2010 guarantees
health for all Kenyans
• Art. 26;Every person has the right to life
• Art.42; Every person has the right to a clean
and healthy environment
• Art. 43. (1) Every person has the right (a) to
the highest attainable standard of health,
which includes the right to health care
services, including reproductive health care
38. 2010 Constitution ctd..
• 53. (1) Every child has the right––(c) to basic
nutrition, shelter and health care
• 56. The State shall put in place affirmative
action programmes designed to ensure that
minorities and marginalised groups—(e) have
reasonable access to water, health services and
infrastructure
39. Why devolve the health system
• To promote access to health services through out
Kenya
• To address discrimination of the “low potential
areas”. Urban areas have had better health
services than rural area
• To address problems of bureaucracy in matters of
health service provision especially procurement
related problems
• To promote efficiency in the delivery of health
services
• Address problems of low quality of health
services
