2.1 Study setting
Kenya is a lower-middle-income country in East Africa with a decentralised form of government comprised of a national government and 47 county governments. The health system in Kenya is organised around four tiers made up of six levels of care: Tier 1 – is comprised of community units or Level 1 of care; Tier 2 – this is made up of primary care facilities comprised of dispensaries, clinics, and health centres which are clustered as Level 2 and 3 facilities respectively; Tier 3 – these are the county hospitals made up of Level 4 (primary care hospitals) and Level 5 (secondary care hospitals), and Tier 4 – comprising of the national referral hospitals or Level 6 of care.
Health is one of the devolved functions in Kenya. Inter alia, the national government is tasked with developing health policy and managing national referral hospitals (Tier 4/Level 6 hospitals) whereas county governments own and run lower-level public facilities (Tiers 1 to 3).
We conducted this study in two purposefully selected counties in Kenya, Nyeri and Makueni. The counties were included in this study to represent a county which had piloted the national-level universal health coverage (UHC) programme (Nyeri) and a county (Makueni) that had both not implemented the UHC pilot but also had a locally-run UHC programme. The use of the UHC programme implementation criteria in the inclusion of the study counties was to provide useful information to support the UHC scale-up in Kenya and particularly through NHIF which has been selected as the ‘vehicle’ to drive the UHC agenda in Kenya. Table 1 highlights the demographic and selected health indicators of the two selected study counties.
Table 1 – Distribution of demographic and selected health financing indicators in Kenya and the two selected study counties.