Thesis
MSc Epidemiology and Biostatistics Research
Financial Determinants of Effective Hypertension and Diabetes Care in Rural Primary Health Facilities in Kisumu, Kenya: A Mixed Methods Study
Forthcoming in BMC Public Health · Final thesis stage
Abstract
Background: Noncommunicable diseases, including hypertension and diabetes, account for approximately 27 percent of all deaths in Kenya, while 26 percent of adults have elevated blood pressure. Despite devolution of health services to county governments in 2013, financing for chronic disease management at the primary health care level remains weak. This study examined financial determinants shaping hypertension and diabetes care in rural Kisumu County.
Methods: We conducted a convergent parallel mixed-methods cross-sectional study in seven public primary health care facilities in Seme Sub-County. Quantitative data came from structured questionnaires and retrospective document review of financial records from January to August 2024. Qualitative data came from key informant interviews with facility in-charges. Descriptive statistics were produced in STATA v16 and qualitative data were analyzed thematically in R.
Results: All seven facilities prepared annual workplans and budgets, but none achieved comprehensive NCD-specific planning with a dedicated NCD budget line. Funding sources were narrow: 71.4 percent of facilities depended on NHIF reimbursements and donor support, only 28.6 percent received direct county funding, and 57.1 percent relied on just two funding streams. Although all facilities held bank accounts, none had formal financial autonomy. County-level expenditure approval typically took 3 to 4 weeks and sometimes more than 2 months, limiting timely local procurement during stockouts. Frequent medicine stockouts were reported by 85.7 percent of facilities.
Conclusion: Rural primary health care facilities operate under structural governance failures that systematically undermine effective NCD care. The centralization of financial authority at county level, absence of ring-fenced NCD budgets, and misalignment between planning processes and resource allocation create a chronic-care system that can prescribe treatment but cannot reliably sustain it. Strengthening facility decision space, protecting NCD budgets, and reforming disbursement and emergency procurement pathways are critical for equitable chronic care under Kenya’s UHC agenda.
Scientific Contribution
Health financing evidence
Provides facility level empirical evidence on how financing architecture influences continuity of hypertension and diabetes care in a devolved county system.
Operational policy relevance
Links budgeting and approval bottlenecks to medicine availability and practical service delivery outcomes in rural public facilities.
Methods integration
Combines financial records, structured facility data, and leadership interviews to explain both measurable and institutional drivers of chronic care gaps.
Methodology
Design
- Convergent parallel mixed methods
- Cross sectional facility assessment
- Integrated interpretation across data streams
Setting and sample
- Seme Sub County, Kisumu County, Kenya
- Seven public primary health care facilities
- Facility in charge interview participants
Quantitative stream
- Structured financing questionnaires
- Retrospective financial record review
- Descriptive analysis in STATA v16
Qualitative stream
- In depth interviews with facility leaders
- Thematic coding and synthesis in R
- Governance and decision flow interpretation
Key Findings
Planning quality gap
All facilities reported planning processes, but none had a complete NCD planning package with a ring fenced NCD line item.
Funding concentration risk
Most facilities relied on narrow financing streams, mainly NHIF reimbursements and donor support, increasing vulnerability to delays and shocks.
Approval bottlenecks
Facilities had bank accounts but no direct spending authority. Approval pathways at county level delayed procurement actions.
Service continuity impact
Frequent medicine stockouts were reported by 85.7 percent of facilities, with direct implications for continuity of hypertension and diabetes care.
Recommendations
- Establish ring fenced NCD budget lines at facility planning level with protected execution rules.
- Expand facility level spending autonomy for approved essential NCD medicines and diagnostics.
- Introduce faster county disbursement and emergency procurement pathways for critical stockout risk periods.
- Diversify and stabilize financing sources beyond reimbursement and donor dependent channels.
- Build routine facility financing dashboards that track budget release, expenditure cycle time, stockout days, and refill reliability.
- Institutionalize quarterly county facility review forums linking financial performance to NCD service outcomes.
Manuscript and Citation
Forthcoming in BMC Public Health. The PDF linked here is the current author manuscript used for thesis and presentation purposes.
Suggested citation:
Amollo N W, Ogol J, Museve E, Owenga J A, Aduda D O, Onguru D. Financial Determinants of Effective Hypertension and Diabetes Care in Rural Primary Health Facilities in Kisumu, Kenya: A Mixed Methods Study. Forthcoming in BMC Public Health. 2026.