Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya

Abstract

Background Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi’s equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. Methods We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. Results Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. Conclusions If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity.

Evaluating health service coverage in Ghana’s Volta Region using a modified Tanahashi model

“…The Tanahashi model, first developed in a seminal paper in 1978, was modified by UNICEF, the World Health Organization, and the World Bank in 2002 for use in the Marginal Budgeting for Bottlenecks tool to estimate the potential impact, resource needs, costs, and budgeting requirements to strengthen national health systems [14]. This adaptation, applied in analyses in more than 50 countries, is a rare framework that moves attention beyond access to health services and brings quality to the forefront, thus highlighting the effectiveness of health systems interventions and potential opportunities to optimize it [18].…”

Neglected Tropical Diseases as a ‘litmus test’ for Universal Health Coverage? Understanding who is left behind and why in Mass Drug Administration: Lessons from four country contexts

“…There are many tools and frameworks which aim to promote equity analysis and action. The Tanahashi Framework [23] (see Fig 1), a comprehensive framework which demonstrates how, at each coverage level, various factors within the health system work together to influence who has access to services with the potential to lose people at each stage [23, 24]. Thus, the use of the term coverage in the Tanahashi Framework is slightly different to the common use of the term coverage within PC-NTD programmes.…”

“…the number of persons receiving PC divided by the at-risk population or the eligible population) commonly reported by PC-NTD programmes. Despite being relatively old, the 1978 Tanahashi Framework has gained new momentum in facilitating equity analysis supporting the breakdown of various health systems elements that contribute to quality and effective service delivery whilst also unpacking equity concerns at each stage [24]. The five coverage domains that the model draws upon (availability, accessibility, acceptability, contact, and effective coverage) are appropriate for analysing equitable NTD programme delivery which relies on various components of the health system pulling together to ensure that as many people as possible are in receipt of associated medicines[7, 24] and that the best and most equitable ‘drug coverage’ is attained.…”

Monitoring access barriers to health services in the Americas: a mapping of household surveys

“…Most models found are now relatively old, but there has been renewed interest in using them as a tool to understand aspects of equity in access, particularly the Tanahashi model of health service coverage developed in 1978 ( 28 - 30 ). Each model presents distinctive dimensions of access (i.e., availability or geographic accessibility) and highlights the existence of barriers and facilitator within each dimension, although there is considerable overlap between them ( Table 1 ).…”