Critical Success Factors for Deployment of Primary Health Care Networks and their Impact in Kenya

The Government of Kenya through the Bottom-up Economic Transformational Agenda (BETA) acknowledges Primary Health Care (PHC) as a cost-effective and efficient means to achieve Universal Health Coverage (UHC). The aim is to enhance equitable access to high-quality and affordable healthcare for all Kenyan citizens. Primary Health Care Networks (PCNs) are gaining traction as the main mode of achieving PHC in Low-and Middle-Income Countries, and Kenya is no exception. In Kenya, PCNs approach seeks to empower local communities at subcounty level through mobilizing resources and strengthening their decision-making authority to address context specific healthcare needs

are in the process of establishing the first PCN and 6 are awaiting partner readiness.The eight main critical success factors for successful establishment included: County ownership and commitment, availability of Key Policy guidelines and strategies for reference, funding from development partners and donors, leveraging on existing National and County governance structures, multisectoral collaborations and partnerships, tracking of PCN establishment through National PCN observatory and Community engagement.Key process enablers to successful role out included: Meaningful engagement of development and implementing partners, Execution through County trained TOTs, Community engagement through Community Health Workforce and support from National Government.Over time, the Established PCNs in 3 pilot counties have demonstrated significant reduction in facility based maternal mortality, increased access to NCD screening services, coordinated health care workers through MDTs and improved forward and backward referrals.Additionally, incorporated innovation models within PCNs have improved access to medical supplies and specialized healthcare services at level 2 and 3 facilities.To achieve successful scale up of PCNs and sustainability for impact it is critical to contextualize PCNs to the County needs, establish sustainable primary health care financing mechanism for PCN activities, Strengthen PCN governance structures and utilise PCN observatory to continuously track PCN performance measurements and decision making.Adoption of a unified focus on PCN performance improvement including one PCN strategy, one action plan on how to optimally implement PCNs and one monitoring framework is critical.If implemented successfully, PCNs will contribute to long term social return on investments and improved health indicators for the Country.

INTRODUCTION
Achieving Universal Health Coverage (UHC) requires the implementation of Primary Health Care (PHC) models that effectively target and optimally address inequalities in healthcare access and utilisation(1).Available evidence indicates that healthcare systems centred around primary health care exhibit improved health outcomes, greater equity, and enhanced efficiency when they prioritize a people-centred approach, tailor their services to address specific community requirements, empower communities to take charge of their health, and promote the utilization of integrated healthcare services(2).Additionally, high-performing primary health care systems are critical to improving health outcomes and achieving universal health coverage.
In Kenya, the government's Bottom-Up Economic Transformational Agenda (BETA)(3,4) places primary healthcare at the forefront of efforts to achieve Universal Health Coverage.The prioritization of primary health care in BETA aims to ensure that all Kenyan citizens have access to high-quality, affordable healthcare services.This is to be achieved through the establishment of efficient healthcare delivery systems.Primary Health Care Networks (PCNs) are gaining popularity in Low-and Middleincome countries, and Kenya is no exception to this trend (5,6).PCNs have proven to be effective models for delivering Primary Health Care (PHC).(7,8).It is clear that adopting the PCN model can address approximately 80% of an individual's healthcare needs throughout their life (9).This effectiveness arises from the PCN's focus not only on managing diseases once they occur but also on promoting health and preventing diseases through Community Health Units (CHUs), which serve as the foundational units of healthcare delivery (10) PCNs play a vital role in efficiently delivering PHC services, reducing fragmentation, and providing advanced care when needed.An added advantage of PCNs is the focus on both promotive, preventive, and curative care provided by integrated teams that ensure continuity of care in existing referral and counter-referral systems.Moreover, PCNs address healthcare access inequity gaps by bringing basic healthcare services closer to communities.This is achieved through an empowered Community Health Workforce, well-equipped PHC facilities (Spokes) and Multi-disciplinary teams (MDT) who offer proximal manageable complicated cases and ensure prompt referral of complicated cases to sub-county referral Hospitals (Hubs).Furthermore, through a SMART (Digitised PCN), there is seamless flow in data generation, data management and use for decision making based on the streamlined and Interoperable Health Information Systems; Electronic Community Health Information System (eCHIS) at Community level, Electronic Medical Records (eMR) at facility level, dashboards at different levels and Kenya Health Information System (KHIS).The strengthened HMIS system across the levels of healthcare service delivery will ensure optimal use of data generated, strengthen follow up of patients and disease surveillance in a PCN and promote efficient use of resources for decision making.

Legal and Policy Framework for PCNs as Pathways for Pathways
In order to strengthen PHC as a critical pathway for achieving The Facility Improvement Financing Bill 2023 provides for an efficient, accountable mechanism for the collection, retention and management of revenue derived from health services rendered at public health facilities in Kenya.The Act further aims to establish a governance framework that will facilitate effective planning, coordination, mobilisation and access of public health facilities improvement financing in Kenya.Additionally, it provides for the appropriation, management and use of retained health services revenue to supplement operations and facilitate quality service delivery in the public health facility promote equitable health facilities improvement financing including benefit sharing in accordance with the relevant laws of Kenya.Finally, provide for a unified system to guide financial management in public health facilities, improving efficiency and effectiveness, and ultimately quality health service delivery.The Bill is significant in the context of a PCN since the revenue generated will be used to finance primary and preventive health care activities at PHC facility and community level.Additionally, the funds will aid in addressing the health system challenges including ensuring adequate essential medicines and supplies, human resources for health, health service delivery and health system gaps.
The social Health Insurance Bill aims to provide affordable, quality health services to all citizens regardless of their economic status and or location.The proposed bill aims to increase ggovernment funding and infrastructure investment to improve public health facilities across the country including increasing PHC Facilities, ensuring adequate medical equipment and trained staff and this will be significant mostly in rural areas where these gaps are rampant.Additionally, ensure the vulnerable and lowincome households receive subsidized national health insurance to help pay for care supported by government.Furthermore, the PHC Fund Bill 2023 encompasses the necessity of a legal framework for community health implementation, public financing of PHC, improvement of PHC service delivery, reinforcement of PHC coordination, the government's commitment to PHC for Universal Health Coverage (UHC), and the relevance of PHC within the context of BETA healthcare priorities.The fund will also provide Emergency, Chronic and Critical Illness Fund to defray the costs of management of chronic illnesses after depletion of the social health insurance cover and cover the costs of emergency treatment.
Moreover, the Digital Health Bill 2023 (15) will regulate financing, reporting and data sharing practices at PHC level.Despite availability of these policy and legal documents, there is a noticeable absence of clear information regarding how contextual factors influence the establishment, execution, and long-term viability of PCNs and how these can be addressed.For instance, how different will PCN designed for rural, urban, arid, or semi-arid regions be structured to meet the needs of the populations?Similarly, what might a PCN model of care for a migratory population look like?How about communities that have both migratory and static populations?How should such PCNs be set up? Additionally, the documents do not adequately address the gaps in the linkage between Community Health Strategy, Spokes and Hubs; critical areas that ought to be addressed to ensure success of PCNs in improving the health of communities.Moreover, from PHC levers perspectives, what are the standards that define a PCN in terms of Leadership and Governance, Human resources for Health, Health Care financing, Health Care infrastructure, Health Products and Technologies and Health Information Systems?

RAPID DEPLOYMENT OF PCNS IN KENYA: KEY SUCCESS CRITICAL FACTORS
In Kenya, the PCNs are premised on a Hub and Spoke model supported by Multi-Disciplinary Teams (MDTs).In this model, health services offered from level 1 to level 4 are designed to provide high quality, integrated and peoplecentred services at the first point of contact with the health care system and strengthening referral between the Community Hubs and Spokes.In 2020, Kenya piloted PCNs in Kisumu, Garissa and Kwale as stipulated in the PHC framework (9).The objective was to demonstrate the effectiveness of the approach and to utilize learnings from the process to inform the scale-up of PCNs in the country.The process adopted a cocreation approach; PCNs were set up using critical steps as in the pictogram below: Pokot, Bungoma, Kilifi, Samburu, Tharaka Nithi, Busia, Elgeyo-Marakwet, Embu, Homa Bay, Kakamega, Kisii, Laikipia, Nakuru, Nyamira, Trans Nzoia, Turkana, Kitui, Narok, Bomet, Embu, Nyeri, Migori, Machakos, Nakuru, Busia, Siaya, Uasin Gishu, Marsabit, Lamu, Tana River, Isiolo and Vihiga Counties.The process is partner led, funded, and supported by donors and implementing partners as highlighted in the snippet of the PCN observatory developed with support from Amref Health Africa indicated in Figure 4 below

What were the Challenges to the Roll out Process?
The process noted significant challenges experienced below: • Inadequate ownership by the CHMT and SCHMT: Enthusiasm from the county health managers could be better.CHMT not ready to train and cascade training to the lower levels even after training.
• Weak stakeholder mapping and analysis: stakeholder mapping, analysis and engagement was not conducted optimally at counties leading to some county partners being not involved in all PCN activities due to the rushed plans.
• Sub-optimal capacity building: Capacity building of the different participants was not adequately done due to a packed program and hence the family physician and County Health Management team (CHMT) members to be trained as Master trainers to aid in refreshers.
• Incomprehensive dissemination of baseline assessment tools: The tool used for baseline assessment tool was inadequately discussed with the data collection team but the program included a national Ministry of Health (MoH) officer in each data collection team to offer Technical Assistance (TA).
• Poor linkages: There was poor linkage between CHUs and PHC facilities in some counties.
• Lack of harmonized allowances and payment: Payment of stipends has so far not prioritized making delivery of CHS a challenge in some counties.

What Were the Key Lessons Learnt?
The key lessons learnt during the process include: County Ownership: It is clear that garnering the support and approval of county authorities is crucial for the successful implementation of Primary Health Care Networks (PCNs).In some instances, certain counties may not take proactive steps in adopting PCNs, instead relying on national staff.To facilitate a swift deployment, it is vital to involve the County Health Governance structures, including the Council of Governors, County Health Management Teams, Subcounty Health Management Teams, Health Facility Management Teams, and Community Health Committees.This involvement can be achieved through county entry meetings and collaborative workshops, ensuring that the consultative process remains continuous throughout the entire PCN lifecycle, spanning from design and implementation to ongoing monitoring and evaluation.This approach guarantees ongoing updates, regular assessments of progress, and the integration of findings to promote sustainability.Securing political support and nurturing county ownership of Primary Health Care (PHC) support is of paramount importance.This requires active engagement with political leadership during both the planning and execution phases of Primary Health Care Networks (PCNs).

Contextualization of PCN to align to the County Context:
The National Government should prioritize considering contextual differences and actively involve counties and additional stakeholders in the inception and formulation of Primary Healthcare (PHC) Policies and Primary Health Care Network (PCN) guidelines.This approach is crucial to ensure the seamless integration and adoption of healthcare policies at the county level.For instance, what would a PCN framework look like in rural, urban, arid, and semiarid regions?How can we design a PCN model tailored to the needs of migratory populations?What is the best approach for communities with both migratory and static populations?These are vital questions that need to be addressed when establishing PCNs.

Stakeholder Identification, Mapping, and analysis:
Fortification of multi-sectoral collaborations and partnerships is necessary to enhance the synergistic alignment of resources and efforts.Currently PCNs implementation is highly dependent on partner's support.Successful implementation of PCNs requires identification of stakeholders, understanding their relationships, levels of support for PCNs and understanding critical contextual factors that hinder facilitate or hinder successful implementation.Early identification and engagement of partners successfully led to successful troll out of PCNs in selected counties.

Adoption of Cost-effective Deployment strategy:
Teamwork and synergy is essential in running parallel sessions.Through a co-creation process, it is critical to set up a PCN deployment plan with the county leadership and relevant stakeholders.This will entail mapping of key stakeholders/partners to support the process.Training of County TOTs on the PCN establishment process was identified as the most ideal strategy.However, it is critical to have an accountability mechanism for the TOTs to ensure constant high momentum.County ownership should be prioritized as experienced, the CHMTs trained as ToTs did not embrace PCNs hence they did not lead in cascading the capacity building.There should be motivation of staff through continuous trainings and MDT support and for sustainability, there should be county ownership

Sustainable funding Model for PCNs:
Considering the current financing arrangements are sub-optimal under the current fiscal landscape.Health Financing reforms including FIF acts, PHC Funds/ National Social Health Insurance Schemes.This will ensure the MDT is well funded and re-imbursement is made for MDT service delivery by the PCN fund or Social Health Insurance as well as enabling procurement of adequate health products and technologies.

Metrics and Evidence generation:
The baseline utilizes a mixed method approach and is done at sub county level.Data is collected through Secondary analysis of KHIS data to establish baseline status on health indicators, Health Facility Assessment along the 6 PHC Levers, Community Health Unit functionality assessment and Client exit interviews.Establishment of a PHC observatory to act as a one stop shop solution to track PCNs implementation is critical.Also, in order to facilitate the delivery of person-centred healthcare services, it is imperative to enhance the capacity for data demand generation and utilization.

Human Resources for Health including CHPs capacity building:
There is need to capacity build HRH on PCNs through initial training and mentorships to maintain the momentum on PCNs.Capacity building should be focused at all levels of PCNs including upskilling of CHPs for quality community health services, reorientation of PHC facility staff to embrace PCNs, Continuous capacity building of MDT to offer context specific support of PHC services and mentorships of Hub Staff to support all lower levels of PHC.Continuous medical education of PCN HRH should be embraced.,

Quality Control and gazettement of PCNs:
Ensure the validation and verification of the Sustainability stage of establishing Primary Health Care Networks (PCNs).This phase encompasses the transition to dispensarization, implementing service delivery according to the established model, conducting tenacious support supervision and mentorship programs, facilitating knowledge exchange, and expanding the reach of PCNs to other regions.

What has been the Impact of PCNs set up in Pilot Phase? Case of Kwale County
Primary Health Care Networks (PCNs) have demonstrated their effectiveness in enhancing the utilization of preventive and promotive healthcare services, expanding access to well-equipped primary healthcare facilities, and fortifying the screening of cases, management by MDT and seamless referrals, ultimately leading to improved healthcare indicators.A noteworthy example of this impact is evident in the case of Lunga lunga in Kwale County, where PCNs were established between November 2022 and February 2023.Data after PCN establishment, indicate, maternal mortality ratio reduced dramatically to 0 deaths per 100,000 deliveries in the second quarter of 2023, compared to 149 deaths per 100,000 deliveries in 2022.Moreover, within a span of just three months after the establishment of PCNs, approximately 260 new cases of Hypertension and Type 2 Diabetes mellitus were screened, managed by the MDT and complicated cases managed by the MDT proximal to their residence.With the nationwide implementation of PCNs, it is anticipated that both morbidity and mortality rates will witness significant declines.

IMPLICATIONS AND RECOMMENDATIONS
The Lastly, to measure the success, there should be an active PHC observatory with monthly data updates, quarterly reviews, and comprehensive annual status reports.There should be enhanced evidence-based learning for decision-making and the need to embrace implementation research and impact studies to measure effectiveness of PCNs on population outcomes.This is illustrated in the framework in Figure 5 below: Contextualization of PCN Models to the County: County contexts differ significantly, with variations in geography, health care system maturity and socio-cultural lifestyles.The nature of service delivery models, and other significant social, economic, and cultural factors are diverse and need to be considered in establishing PCNs in order to address the varied needs.For instance, when designing a PCN, the setup processes and resource needs may vary between Garissa County and Kericho County.Therefore, it is crucial for the National Government to consider contextual variations and actively involve counties from the initial stages of conceiving and crafting Primary Health Care Policies and guidelines for Primary Health Care Networks.This approach facilitates smooth implementation of healthcare policies at the County Level, taking into account contextual factors.
Establish sustainable primary health care financing: -Both the national and county governments should establish sustainable PHC financing models to ensure successful roll out and sustainability of PCNs.Prior to establishment of PCNs, it is important to establish costed workplans detailing critical activities to be undertaken and allocating sufficient resources.PCN performance measurement: Development of frameworks for gathering measurements and generating evidence, tailored to the performance of County Primary Healthcare (PHC) systems.This will promote adaptive learning throughout the entire process of PCN roll out from establishment, functionality, and effectiveness.The National and County Governments, in partnership with various stakeholders, should work together to create a well-defined results framework, metrics, and a sustainability mechanism plan to ensure the success of each Primary Health Care Networks (PCN).Essential tools that have facilitated this effort include the Primary Health Care Network Observatory, which plays a vital role in providing real-time updates on the PCN rollout progress and thereby contributes significantly to the impact of these networks.It is crucial to establish a comprehensive learning agenda that encompasses key learning objectives, learning activities like baseline assessments, implementation research, and the utilization of data analytics to generate evidence.
Multi-sectoral collaborations and partnerships: This is necessary to enhance the synergistic alignment of resources and efforts.The stakeholders will support with resources and technical expertise in the establishment, monitoring, social accountability, and sustaining of PCNs.This involves Stakeholder mapping, analysis, and participation in PCN activities as envisaged in the PHC Bill.

Figure 1 :
Figure 1: Primary Care Network Structure

Figure 2 :
Figure 2: Process undertaken setting up Primary Health Care Networks

Figure 3 :
Figure 3: Critical factors for successful roll out and sustainability of PCNs Adoption of a unified focus on PCN performance improvement including one PCN strategy, One action plan on how to optimally implement PCNs and one monitoring framework is critical.For successful PCN set-up and sustainability, first, there has to be county ownership through political commitment and good will and leadership, prioritisation of Primary Care Networks in County Integrated Development Plans and having PCN County Champions.Secondly, there should be sustainable financing both at national and county levels achieved through National Budget or Financing Policy to su[pport PCNs, County Costed PCN plans in place and diversify funding sources for PCNs including Allocation from County Budgets and Stakeholder commitments.Third, there should be a clear and functional governance and accountability mechanisms.For instance, a functional PCN coordination mechanisms in place, functional social accountability mechanisms through community engagement and commitments tracker for PHC/PCN financing and operationalization.
Primary Health Care Division at the National level should advocate and lobby for funds reallocation through the health sector working group to support the PCN agenda.At County level, advocate for funding through County Assembly Health Committee to review CIDPs, supplementary budgets, and the Annual work plans to include PCN activities and reallocate funds.Advocate for county adoption and implementation of the Health Facility Improvement Fund Act to ensure sustainable funding for Primary Health Care facilities.Furthermore, assess and update Health Facility Action Plans to incorporate Primary Care Network (PCN) initiatives and allocate financial resources accordingly.Strengthen PCN governance structurers: County governments should establish and or strengthen PHC governance structures and accountability measures including functional coordination mechanisms, functional social accountability mechanisms and commitment trackers.The governance structures should be all inclusive to ensure community participation and ownership, involvement of Civil Society Organization, and diverse stakeholders.These are critical prior to establishment of Primary Health Care Networks.