Abstract
Background: Primary healthcare facility managers (PHFMs) occupy a unique position in the primary healthcare system, as the only cadre combining frontline clinical activities with managerial responsibilities. Often serving as ‘street-level bureaucrats,’ their perspectives can provide contextually relevant information about interventions for strengthening primary healthcare delivery, yet such perspectives are under-represented in the literature on primary healthcare strengthening. Our objective in this study was to explore perspectives of PHFMs in western Kenya regarding how to leverage human resource factors to improve immunization programs, in order to draw lessons for strengthening of primary healthcare delivery. Methods: We employed a sequential mixed methods approach. We conducted in-depth interviews with key informants in Kakamega County. Emergent themes guided questionnaire development for a cross-sectional survey. We randomly selected 94 facility managers for the survey which included questions about workload, effects of workload on immunization program, and appropriate measures to address workload effects. Participants provided self-assessment of their general motivation at work, their specific motivation to ensure that all children in their catchment areas were fully immunized, and recommendations to improve motivation. Participants were asked about frequency of supervisory visits, supervisor activities during those visits, and how to improve supervision. Results: The most frequently reported consequences of high workload were reduced accuracy of vaccination records (47%) and poor client counseling (47%). Hiring more clinical staff was identified as an effective remedy to high workload (69%). Few respondents (20%) felt highly motivated to ensure full immunization coverage and only 13% reported being very motivated to execute their role as a health worker generally. Increasing frequency of supervisory visits and acting on the feedback received during those visits were mostly perceived as important measures to improve program effectiveness. Conclusion: Besides increasing the number of staff providing clinical care, PHFMs endorsed introducing some financial incentives contingent on specified targets and making supervisory visits meaningful with action on feedback as strategies to increase program effectiveness in primary healthcare facilities in Kenya. Targeting health worker motivation and promoting supportive supervision may reduce missed opportunities and poor client counseling in primary healthcare facilities in Kenya.
Highlights
Primary healthcare facilities are often the most accessible point of care in the public healthcare system for communities in sub-Saharan Africa
primary healthcare facility managers (PHFMs) occupy a unique position in the primary healthcare system, where their perspectives, capacities and attitudes often shape how the public experience healthcare
Immunization prevents more than 2.5 million child deaths each year, but over 19 million infants are left unprotected against vaccinepreventable diseases (VPDs), with the poorest effective coverage in sub-Saharan Africa.[13]
Summary
Inadequate coverage is often driven by patients’ geographical distance to health facilities, poverty, and lack of trust in the healthcare system.[7,20] supply related factors are key determinants of coverage, including vaccine availability, vaccine infrastructure and storage, and human resources.[21] A recent qualitative analysis of perspectives of government officials on internal accountability in Nigeria’s routine immunization programs highlighted the importance of human resource factors and workplace environment for program performance.[22] In Kenya, PHFMs have broad responsibilities related to the immunization program, ranging from forecasting vaccine needs and data management, acquisition of vaccine stock from regional depots, maintenance of stock in the facility, management of antenatal and child care clinics, and coordination of community healthcare workers.[23] Despite their unique position, there is paucity of studies documenting PHFM perspectives on how to improve program delivery, or their insights into challenges and strategies for last mile delivery. Our objective in this paper is to explore perspectives of PHFMs in western Kenya regarding the influence of human resource factors on immunization programs in order to draw lessons for strengthening of primary healthcare delivery
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