Health care reforms in Kenya: the performance of District Health Management Boards (Dhmbs) in the Coast Province of Kenya.

Abstract

. The purpose of this dissertation was to examine the performance of District Health

Management Boards (DHMBs) and assess their effectiveness in improving the quality of services in Kenya's public health care facilities since introduction of the health care reforms. More specifically, using the case of Coast Province, the study attempts to use selected indicators such as supervision of cost sharing activities, members' commitment on the boards work, achievement of the goal of improving quality of services and expenditure of cost sharing funds to measure the effectiveness of the DHMBs in implementing the recently 'introduced health care reforms in Kenya. In addition, the study attempts to identify and understand factors that explain variations in (1) users' satisfaction with the quality of services provided by selected public health care facilities and (2) the acceptability of cost sharing in these facilities. The study hypothesized that: The background characteristics of the users and their perceptions of the quality of services determine (i) their satisfaction with health care services and (ii) their acceptability of the user fees.

A sample of 250 users of randomly selected district hospitals in Coast Province provided the survey data needed for the study. This sample was selected using both the probability and non-probability sampling techniques. Using the survey data, the study formulates two multiple regression models to estimate variations in (1) users' satisfaction with the quality of health care services and (2) acceptability of the user fees. In addition, qualitative data from the Focus Group Discussions (FGDs) with the officials of DHMBs and providers of health care services and secondary data were used to supplement survey data. Data for examining the performance of the DHMBs and assessing their

effectiveness in improving the quality of services were obtained from 75 purposively selected participants of FGDs. They included 15 officials of DHMBs and 60 participants comprising various cadres of medical providers.

The study reports several findings related to policy formulations in the health sector. First, findings of the study reveal that drug availability, adequacy of diagnosis, staff effectiveness, level of cleanliness of the facilities, level of users' education, quality of meals at the hospitals and staff attitudes are important predictors of users' satisfaction with the services. Second, drug availability, level of cleanliness of the studied facilities, employment status of users and quality of meals were found to significantly influence acceptability of the user fees in Coast Province.

Further, this study has several findings related to management policy reforms in Kenya's health sector. For instance, findings of this study suggest that the formation of the DHMBs as an attempt to improve the health care management may not be a panacea for the many problems within Kenya's health sector. Accordingly, the study recommends that unless the problems of poor decision making, inadequate resources, lack of effective .management skills and lack of autonomy of the DHMBs are addressed, the potential of health care decentralization through the DHMBs will not be realised in Kenya.

Finally, the study reveals that despite the lack of consensus on the subject of user fees, users' perception of the charges is an important determinant of acceptability of the user fees in coast province. More specifically, affordability of the government charges tends to

significantly enhance the acceptability of the user fees. In addition, data from the Focus Group Discussions with the DHMBs officials and various cadres of providers suggest that if efficiency in the use of the revenue to improve quality of services is achieved, DHMBs could successfully boost the acceptability of the user fees in the province.