Abstract

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and "street-level" SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers' confidence in the system. The intermediaries also reduced bureaucrats' ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers' power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Highlights

  • The United Nations Sustainable Development Goals (SDG) call for all countries to achieve Universal Health Coverage (UHC) by 2030

  • Mr Owino was involved in the African Health Markets for Equity (AHME) intervention and brought both his experience and wealth of knowledge regarding the National Hospital Insurance Fund (NHIF) to bear on this paper

  • With Mr Owino’s help, we were able to integrate information that we hope offers a more robust depiction of the street-level bureaucrats themselves, the obstacles they face to doing their job well, and the various ways in which they interact with providers

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Summary

Introduction

The United Nations Sustainable Development Goals (SDG) call for all countries to achieve Universal Health Coverage (UHC) by 2030 Achieving this goal will require expanding both health financing and service availability. Private providers often must go through an onerous accreditation process to enroll in these schemes The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. The intermediaries reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats

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