Abstract
The low health outcomes and inequities problems in developing countries are due to ineffective gate keeping at the Primary Health Care (PHC) level, non-adherence to policy and dysfunctional health infrastructure. This study was conducted at 100 PHC centres sampled using Taro Yamane formula, in Machakos County, Kenya, from March to May 2015. It involved 8 gender-based focus group discussions (FGDs) with patients and their caretakers. Qualitative and quantitative data were collected from emancipated children and adults aged 15-65 years excluding the disabled due to data integrity issues. The Statistical Package for Social Science (SPSS) version 20.0 and Atlas.ti 7 software were used for data analysis. Correlation was done using the Spearman rho test and significance was set at <0.05. A questionnaire return rate of 83% was achieved of whom 84.3% were nurses (p<0.001) nurses and 15.7% were diploma holders in clinical medicine (clinical officers). The health workers were young (P<0.001) and married (p<0.001). A proportional relationship (rho=0.383, p< .001) existed between the number of out-patients received and cases referred to hospitals. Most gatekeepers were ignorant (p=0.04) about the Policy on the patients’ referral yet they did not officially refer patients (80.7%). Most (63.5%) of the hospitals receiving self-referrals did not ask for referral letters. Policy and referral letters were found to be necessary (p=0.004). The gatekeepers’ non-adherence to policy, lack of laboratory services and shortages of drugs contributed to self-referral by patients, creating a burden on the resources for healthcare, resulting in inefficiency at the PHC level. This study recommends a review of the gatekeeping system at the PHC level, capacity building, quality assurance, redefinition and strengthening of the office of the gatekeepers, regularization of supplies and reinforcement of the patient referral policy, staff motivation and best practices in customer care.
Highlights
Health outcomes are low among many developing countries and the inequities in health status are challenges from which no country in the world is exempt [1]
This study found out that there was a relationship between the presence of policy requiring a patient to consult first at the Primary Health Care (PHC) facilities and the need for referral letters to visit the secondary health care (SHC) (p=0.004) in which more people were ignorant of the policy
An inference based on these findings could be made that the 63.5% of the patients with preventable diseases who bypassed the PHC facilities in Machakos County, Kenya, to seek health care for non-preventable diseases at Tiers 3 and 4 which specialized in curative health care caused a major dissonance in the preparedness of hospitals to cater for preventable diseases, a manpower misallocation and misplacement, a supplies inequity and inequality, a management and emergency crisis, a resources misallocation, mismatch and misuse of resources, a surge and pressure by patients on the limited and incompatible resources at Tiers 3 and 4 and under-utilization of resources and services at the PHC level (Tier 2)
Summary
Health outcomes are low among many developing countries and the inequities in health status are challenges from which no country in the world is exempt [1]. Primary Health Care (PHC) is viewed by many countries to be the backbone of a rational health care system [2]. It was envisaged to be the first level of contact of individual patients, their families and communities with the national health systems, bringing health care as close as possible to the people and constituting the first element of a continuing health care process [4]. Good health policies exist at the national level of the Kenyan Health System but challenges lie in the implementation process [6]. Some Countries have successfully implemented their policies [7].
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