BackgroundPrivate sector availability and use of malaria rapid diagnostic tests (RDTs) lags behind the public sector in Kenya. Increasing channels through which quality malaria diagnostic services are available can improve access to testing and help meet the target of universal diagnostic testing. Registered pharmacies are currently not permitted to perform blood tests, and evidence of whether malaria RDTs can be used by non-laboratory private providers in line with the national malaria control guidelines is required to inform ongoing policy discussions in Kenya.MethodsTwo rounds of descriptive cross-sectional exit interviews and mystery client surveys were conducted at private health facilities and registered pharmacies in 2014 and 2015, 6 and 18 months into a multi-country project to prime the private sector market for the introduction of RDTs. Data were collected on reported RDT use, medicines received and prescribed, and case management of malaria test-negative mystery clients. Analysis compared outcomes at facilities and pharmacies independently for the two survey rounds.ResultsAcross two rounds, 534 and 633 clients (including patients) from 130 and 120 outlets were interviewed, and 214 and 250 mystery client visits were completed. Reported testing by any malaria diagnostic test was higher in private health facilities than registered pharmacies in both rounds (2014: 85.6% vs. 60.8%, p < 0.001; 2015: 85.3% vs. 56.3%, p < 0.001). In registered pharmacies, testing by RDT was 52.1% in 2014 and 56.3% in 2015. At least 75% of test-positive patients received artemisinin-based combination therapy (ACT) in both rounds, with no significant difference between outlet types in either round. Provision of any anti-malarial for test-negative patients ranged from 0 to 13.9% across outlet types and rounds. In 2015, mystery clients received the correct (negative) diagnosis and did not receive an anti-malarial in 75.5% of visits to private health facilities and in 78.4% of visits to registered pharmacies.ConclusionsNon-laboratory staff working in registered pharmacies in Kenya can follow national guidelines for diagnosis with RDTs when provided with the same level of training and supervision as private health facility staff. Performance and compliance to treatment recommendations are comparable to diagnostic testing outcomes recorded in private health facilities.

BackgroundSince 2004, Kenya’s national malaria treatment guidelines have stipulated artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated malaria, and since 2014, confirmatory diagnosis of malaria in all cases before treatment has been recommended. A number of strategies to support national guidelines have been implemented in the public and private sectors in recent years. A nationally-representative malaria outlet survey, implemented across four epidemiological zones, was conducted between June and August 2016 to provide practical evidence to inform strategies and policies in Kenya towards achieving national malaria control goals.ResultsA total of 17,852 outlets were screened and 2271 outlets were eligible and interviewed. 78.3% of all screened public health facilities stocked both malaria diagnostic testing and quality-assured ACT (QAACT). Sulfadoxine–pyrimethamine (SP) for intermittent preventive treatment in pregnancy was available in 70% of public health facilities in endemic areas where it is recommended for treatment. SP was rarely found in the public sector outside of the endemic areas (< 0.5%). The anti-malaria stocking private sector had lower levels of QAACT (46.7%) and malaria blood testing (20.8%) availability but accounted for majority of anti-malarial distribution (70.6% of the national market share). More than 40% of anti-malarials were distributed by unregistered pharmacies (37.3%) and general retailers (7.1%). QAACT accounted for 58.2% of the total anti-malarial market share, while market share for non-QAACT was 15.8% and for SP, 24.8%. In endemic areas, 74.9% of anti-malarials distributed were QAACT. Elsewhere, QAACT market share was 49.4% in the endemic-prone areas, 33.2% in seasonal-transmission areas and 37.9% in low-risk areas.ConclusionAlthough public sector availability of QAACT and malaria diagnosis is relatively high, there is a gap in availability of both testing and treatment that must be addressed. The private sector in Kenya, where the majority of anti-malarials are distributed, is also critical for achieving universal coverage with appropriate malaria case management. There is need for a renewed commitment and effective strategies to ensure access to affordable QAACT and confirmatory testing in the private sector, and should consider how to address malaria case management among informal providers responsible for a substantial proportion of the anti-malarial market share.Electronic supplementary materialThe online version of this article (10.1186/s12936-017-2089-0) contains supplementary material, which is available to authorized users.

Background  Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions.  Health system functions may also influence the health system’s ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic. Methods We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Results Purchasing arrangements:  COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme’s benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Conclusions Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources.  Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

Background: Kenya has committed to achieving universal health coverage (UHC) by 2030 and has prioritized purchasing reforms. Enhancing effective provider-purchaser engagements is quintessential to transitioning to strategic purchasing reforms on provider selection or empanelment, benefits package design and provider payments mechanism. This study assessed the challenges hindering effective provider-purchaser engagement in Kenya and proposed actionable solutions to policymakers and actors. Methods: The study applied a cross-sectional qualitative study design. Data was collected using interviews – incorporating both focus group discussions (FGDs), in-depth interviews (IDIs) and a consensus-building workshop with stakeholders representing healthcare providers, medical professional bodies, the National Hospital Insurance Fund (NHIF – at county/branch and national level), health insurance beneficiaries, the Council of Governors (COG) and the ministry of health (MOH). Purposive sampling was employed to select stakeholder representatives for each of the stakeholder clusters. Results: Provider-purchaser challenges were identified to result from 1) human resource gaps (understaffing and staff turnover), 2) infrastructure gaps (both hardware and software), 3) knowledge and skill gaps, and 4) governance issues attributed to bureaucratic processes, poor accountability mechanisms and poor mechanisms of communication between providers and purchasers. Providers and purchasers emphasized the need for 1) automation of processes, 2) review of provider payment mechanisms (PPMs), 3) regular capacity building of providers, 4) effective communication and accountability and 5) development of public-private contracting frameworks as key actionable solutions for implementation. Conclusion: Challenges hindering effective provider-purchaser engagements result largely from human resources, infrastructure, capacity, communication and accountability gaps. Reforms aimed at addressing these gaps must focus on building staff capacity in the payment process , employment or prioritization of staff to the payment process, adoption of information systems or technology to automate processes (both on empanelment and payment) and establishment of working communication channels (both automated and in-person processes) that are regular. Such reforms should be tailored to the stakeholders' actions and monitored to ensure adequate implementation to enhance provider-purchaser engagements.