Scaling up the Primary Health Integrated Care Project for Chronic Conditions in Kenya: an implementation research project

Kenya faces an increasing number of people with chronic diseases such as high blood pressure (hypertension), high blood sugar (diabetes) and cancer. These diseases account for a large proportion of all deaths and have an important economic impact in Kenya. Also, because poor people cannot pay for the treatment of these diseases they are especially vulnerable. Management of people with these chronic diseases at the community and primary care(public dispensaries or health centres ) is very important. However,
currently in Kenya the emphasis remains on hospitals and specialist services. There are examples of good practice of chronic disease integrated management at primary care in Kenya such as the 'Academic Model Providing Access to Health Care', to provide integrated care for people with HIV (which is a chronic disease). Experiences from this model are now being taken forward by the Ministry of Health (MOH) and the World Bank (WB) to pilot a 'Primary Health Integrated Care Project for Chronic Conditions'
(PIC4C) in Busia and Trans Nzoia counties. This project aims to identify people with hypertension, diabetes, cervical and/or breast cancer in the community and ensure their timely referral and management at the appropriate service level, using a range tools and approaches (e.g. treatment protocols, decision support tools, electronic health records and training of health workers) to ensure that the care patients receive is of high quality. It also links patients with a chronic disease benefit package from the National Hospital
Institutional Fund (NHIF) package to protect people from the costs of these chronic diseases. PIC4C will be implemented from October 2018 and working in partnership with the MOH and the WB we seek to support the scale up of the model across Kenya beyond the pilot sites. To achieve this, we aim to better understand the implementation process and challenges found during the conduct of the pilot. During our project we will conduct interviews, analyse data from the health facilities and household with people with these chronic diseases to better understand how the pilot is implemented. Specifically, we will understand the experiences of patients, health care workers and decision makers involved in the pilot, we will also assess the health impact (how well the patients with high blood pressure, diabetes or cancer included in the PIC4C pilot are treated), and, we will also evaluate whether the NHIF chronic care benefit package protects financially to patients with these chronic diseases and also provides good quality care. Finally,
and most importantly, we are working very closely with members of the government, health care facilities managers and patients to ensure that our study lessons can help to scale up the PIC4C in other places in Kenya beyond the pilot study.

Based on the learning form the AMPATH (Academic Model Providing Access to Health Care) HIV care model a partnership between AMPATH, the Ministry of Health (MOH), the World Bank (WB) and the Access Accelerated Initiative (AAI) has been established for the development and piloting of the Primary Health Integrated Care Project for Chronic Conditions (PIC4C). The PIC4C model includes (i) early case finding of people with hypertension, diabetes, cervical/ breast cancer at service level 1; (ii) structured referral to service providers at level 2 for confirmation of diagnosis and treatment initiation or referral to level 3 or 4 using structured protocols; (iii) initiation of treatment using structured treatment protocols and decision support tools at levels 2, 3 and 4; (iv) retention of patients in care supported by ongoing training of health workers at all care levels; (v) monitoring and evaluation supported by a health information system; and (vi) linking patients in care with a voluntary chronic care benefit package operated by the NHIF (National Hospital Insurance Fund) for sustainable health financing. From October 2018 (funded by the WB and AAI) the PIC4C model is being implemented in 2 counties in western Kenya. Working in partnership with the WB and MOH we aim to support scale up of the PIC4C model. Our specific objectives include: 1) to understand the implementation process; 2) to understand the experiences of patients; 3) to assess the health benefits (and potential unintended consequences), and 4) to evaluate the effectiveness of the NHIF chronic care benefit package. To achieve our objectives we will use mixed methods

Through the current project funded by the WB/AAI, we are already working closely with the key knowledge users (MoH, the World Bank and decision makers at county levels). They have contributed to the key research questions and proposed methods of the proposal. This strong existing partnership will be key to achieve the expected impact of the project. We will build from this strength as early dissemination of emerging insights of the project will be key to inform the scale up of the PIC4C model across Kenya and other countries participating in the WB/AAI initiative. Our strategy will include two formal stakeholder workshops in Q1 2020 and Q1 2021 and a closing policy dialogue in Q1 2022. The workshops will include key stakeholders that are directly and indirectly involved in the PIC4C model development and implementation as well as wider national and international stakeholders, including national and county level political and health system leaders, academic and AMPATH leaders, senior level service providers, civil society, and stakeholders from the other WB/AAI participating countries. The aim of the first stakeholder workshop is to (i) communicate emergent insights from the work carried out in the first months of the project; (ii) actively engage stakeholder and use their knowledge and experience to reflect on emergent findings; and (iii) consult with stakeholders how emergent insights can be used to develop a scale up strategy. It will also provide opportunity for adapting proposed work to ensure that the research meets the information needs of key stakeholders involved in the organisation and governance of the Kenyan health system at county and national levels. The second stakeholder workshop is aimed at (i) reflecting on the interim findings of the work conducted and their implications for the further development of the PIC4C model and the key factors that would need to be in place to allow for the wider scale up of this model (or indeed, an adaption thereof) across Kenya, and (ii) work with stakeholders to begin formulating draft recommendations for a regional and/or national scale up strategy. We also propose holding a final policy dialogue in Q1 2022 in collaboration with the MOH and WB/AAI, which will be aimed at high-level national and international policy-makers seeking to disseminate the findings of the research to a broader policy audience with a view to inform implementation and scale up of integrated primary care approaches beyond Kenya. Policy dialogues are designed as closed meetings to informally discuss the various country experiences in stimulating multi-professional delivery and coordination in primary care, within a broader context of common challenges that health systems face in this field. The meeting will be held under Chatham House rule to allow participants speak freely and share experiences, both positive and negative. Stakeholder workshops and the policy dialogue will be meticulously prepared by the project team to ensure maximum impact. Workshop outcomes will be written up as policy briefs to provide guidance for the further roll-out of the PIC4C or adaptations thereof. Co-Investigator Prof Nolte has extensive experience in facilitating knowledge exchange activities with decision makers. Also, our study will lead to advances in understanding in the area of integrated management of chronic conditions in LMIC and we will disseminate our results via meetings, conferences, and publications.