Health Care Access and Service Delivery in Relations to the Right to Health and Universal Health Coverage: A Case of Machakos County, Kenya (2019-2024)

Health Care Access and Service Delivery in Relations to the Right to Health and Universal Health Coverage: A Case of Machakos County, Kenya (2019-2024)

Yvonne Nduku Mulei, Xavier Francis Ichani

Kenyatta University, Kenya

DOI: https://dx.doi.org/10.47772/IJRISS.2025.905000293

Received: 28 April 2025; Received: 09 May 2025; Accepted: 12 May 2025; Published: 12 June 2025

ABSTRACT

This study investigated health care access and service delivery in relations to right to health and universal health coverage (UHC) in Machakos County, Kenya. The first part examines the views of both patients and health care practitioners on the state of health service delivery and the second part discusses strategies for enhancing health service delivery in Machakos County, Kenya. Descriptive cross-sectional research design was used. The target population was health professional and patients in 198 public healthcare facilities published in the Machakos County Integrated Development Plan (CIDP) 2023-2027. Yamane sampling formula was used to generate a sample of 100 healthcare facilities from the eight Sub-Counties in Machakos County. Stratified sampling formula was then used to group the health facilities according to the size of the population they serve. Purposive and convenience sampling helped in the identification of healthcare officers and patients to participate in the survey as well as to select eight Sub- County Medical Officers that were interviewed as key informants. Questionnaire and interview were used to collect primary data. Analysis of data included descriptive statistics for quantitative data narratives for qualitative data. This study observed that, all states desire their citizens to attain the right to health by achieving universal health coverage. However, due to increase in population and new emerging dynamics within the healthcare access and service delivery such as emerging new disease patterns, resource constraints, among other factors, impede the attainment of universal healthcare in Machakos County, Kenya. This study recommends for increased funding for the health sector to ensure the right to health is realized by all the citizens in Kenya.

Keyterms- Access to health care, Health Service Delivery, Kenya, Machakos County, Universal Health Coverage, Right to Health.

INTRODUCTION

The Right to Health and Universal Health Coverage (UHC) has become a policy priority at both the global, national and County levels in Kenya (HERU Policy Brief, 2019). Available literature shows that Kenya has made remarkable strides towards actualizing Universal Health Coverage (UHC), but achieving ultimate universal health coverage remains a significant challenge for both County and National Government (Okech & Lelegwe, 2015).    According to the Office of the UN High Commission for Human Rights (2008), the right to health is enshrined in the International Committee on    Economic, Social and Cultural Rights, (ICESCR), which include; access to health, healthy environmental conditions, health-related education among others. The right to health gives the population freedom and entitlements for enjoying the highest attainable health, access to essential medicines, standard maternal, reproductive and child health protection as well as equal and timely access to health services on non-discriminatory basis. Member states that have ratified this convention are expected to make provision to prevent and control epidemic and other diseases and create conducive conditions which provide assurance of availability of medical services as well as provision of medical care in the event of sickness among others (UNHCHR, 2008). Therefore, ICESCR expects all member states to fully respect the right to health in all activities. Article 12. ICESCR mandates the government to enhance its national health systems, provide public health goods and services, provide required facilities and all government programs that guarantee adequate maintenance of public health (Kaltenborn, Krajewski & Kuhn, 2020).

Kenya’s ambition to achieve the right to health for all citizens is not only in line with its Vision 2030, but it is also in tandem with the UN Sustainable Development Goal No. 3 where the country targets to achieve universal health coverage that includes; financial risk protection, access to safe, quality, effective and essential healthcare, affordable medicines and vaccines for all. However, the country has not yet met all WHO requirements across all its health infrastructure where 25% of the counties have less than the required minimum of 2 persons per 10,000 population. The country infrastructure is below recommended standard and thus there is inadequate access to basic medical equipment and weak data collection on health status (Ministry of Health, 2020). In Machakos County, Wayua (2017) notes that because of financial challenges, very few residents of Machakos county experience challenges in accessing healthcare service in the county leading to maternal mortality (Kavindu & Wamitu, 2019).

Machakos County located in Eastern part of Kenya has an area coverage of 6208 km², with a population of 1,421,932 people according to the 2019 Kenya Population Census. It has 8 Sub Counties; Yatta, Kangundo, Machakos town, Kathiani, Matungulu, Masinga, Mwala and Mavoko. One of the agendas of the County is to ensure its population live a healthy life hence the investment in healthcare. Currently, there is one level 5 hospital within Machakos town, 4 level four, 43 public health centres and 83 dispensaries (Machakos County, 2018). However, the County does not have adequate health facilities in the rural areas where majority cover more than 5 kilometers to access healthcare services (Machakos County Government, 2015).   Machakos County reportedly has low client satisfaction of access to healthcare and service delivery (Manyeti, 2012).

Statement of the Problem

All citizens have freedom and entitlements to enjoyment of highest attainable health according to the right to Health and Universal Health Coverage in Kenya. Therefore, the state is indebted to ensure citizens have the right to access essential medicines, reproductive, maternal, child health, equal and timely access to health and non-discrimination of healthcare service provision. This means that health facilities within state jurisdiction should be able to function well and have sufficient medical supplies. The health facilities should also be easily accessible by all, be of gender sensitivity and offer quality services. The state therefore, has the obligation to reduce still birth rates, infant mortality, improve industrial hygiene, prevent any epidemic as well as being able to control as well as creating conditions necessary for assurance of medial service and attention to all citizens in case of sickness (Office of the UN High Commission for Human Rights, 2008).

The Constitution of Kenya 2010, has adopted the International Convention on Economic, Cultural and Social Rights (ICECSR) in its approach to health sector advocating for systems; capable of providing the citizens’ rights-based healthcare services which recognizes the rights to highest attainable standard of health in the constitution. The government has taken affirmative actions that ensure all marginalized and minorities have access to health care services as enshrined under Article 53 and 56 of the Kenya Constitution 2010. Through the description of roles in the Fourth Schedule, the National Government of Kenya offers policy direction and technical support while the County Government of Machakos supports health service delivery to the citizens (Kimathi, 2017). The Kenya vision 2030 flagship projects also highlighted the milestones the National Government in partnership with the County Government have undertaken towards achievement of UHC (Mochache, 2021). Because Machakos County was chosen as one of the counties to spearhead the universal health coverage integration, one would expect the County to have enhance right to health among its residents. However, the situation of health service in Machakos County has not taken into consideration all the population rights according to ICESCR, the constitution 2010 and the government vision 2030 which recognizes highest attainable standard of health to all citizens, non- discrimination and putting in place mechanisms to ensure free access to health services. The study    investigated Kenya’s obligations on health access and service delivery in relation to the right to health and universal health coverage in Kenya using the case of Machakos County 2010-2025.

Objectives of the Study

General Objective

The general objective of this study was to investigate Kenya’s obligation on health care access and service delivery in relation to the right to health and universal health coverage using the case of Machakos County, Kenya (2019-2024).

Theoretical Framework

This study utilized three theories namely, the liberal theory, egalitarian rights-based theory and the human rights theory. Locke in 1632 proposed liberal theory, one of the oldest philosophies that is considered a lifestyle since it promotes individual freedom (Moraes, 2019). The theory is based on a philosophy that citizens need to have clear freedom for the pursuit of their goals and interests without the interference by the government. The theory assumes that human beings are rational creatures and that they are created with certain natural rights that cannot be denied or restricted by any authority. This study used this theory to analyze implementation of the right to health by the state, being a party to international treaty, ICESCR. This is based on the international laws, the respect to human dignity and the freedom of all aspects of life such as health. The theory contends that individual’s independence and opinions should be considered during decision making on issues concerning them, gives room for the study to understand how the government develops policies that involve public participation and whether the collaboration between the county and the national government have embraced the idea of having the input of the population on issues affecting their health for purposes of promoting and protecting the right to health. The theory therefore, explained the extent of the government involvement in promoting and protecting the freedom to access health.

Daniels (2013) developed a theory in his attempt to expand Rawls’s theory on liberalism. The theory believes that people ought to receive similar benefits, treatment, or be treated in the same equality. This view point emphasizes that people ought to be treated equally (Ruger, 2006). The theory assumes that all humans are equal in terms of moral standing. The Christian idea that God loves every human soul equally is a significant source of this philosophy in terms of the Western European and Anglo-American philosophical traditions. This means that social institutions that determine how health care is distributed should be set up in a way that allows each person to achieve a fair share of the services that are typically available in that community.

The variety of life goals that a person could logically hope to pursue given their talents or skills determines the normal range of opportunity available. According to this argument, the social responsibility to provide health care comes before and is distinct from the social responsibility to supply other primary goods (Peer, 2013). This theory points out the importance of any community to emphasize the health care needs of the people including service delivery, financing, accessibility, availability, and governance in their effort to promote equal opportunity in universal access to health care. The study used the theory to analyze state compliance to the obligation on all citizens right to universal access to health care as enshrined in the ICECSR. It was also used to develop conceptual framework that assisted in data collection.

The UN (1948) declaration of human rights recognized the right to reasonable standard of life as part of the right to health. Gerisch (2018) adds that this right was acknowledged as a fundamental human right in the 1966 International Convention on Economic, Social and Cultural rights. Since      then, other international human rights agreements have incorporated the right to health and its elements, such as the right to medical treatment. Additionally, in international accords, national laws and regulations, and in conferences around the world, States have promised to protect this right. Meier (2017) observes how organizations that keep an eye on human rights treaties have been paying increasing attention lately to the right to the greatest standard of bodily and mental health. This theory shades light on state obligation in protecting human rights related with universal access to healthcare services. Additionally, the theory helped in developing state policies related to health service delivery, health financing, health governance and collaboration. It therefore enhanced the development of conceptual framework which was used in data collection.

Review of Related Literature

Manzoor et al., (2019) notes how global competition within the healthcare has led to increase in patient expectation of public healthcare services where governments are putting in place policies to enhance their patient’s satisfaction through improved service delivery hence building capacity of its healthcare workforce to enhance their skills as well as investing in healthcare infrastructure. Studies by Manzoor et al., (2019) sought to determine patient satisfaction with health care service using descriptive research design targeting outpatient in three facilities in Pakistan. The study focused on services offered in the laboratory, diagnostic care, prenatal and preventive and how they were affecting satisfaction of patients in public healthcare facilities. The study used convenience sampling to determine a sample consisting of 290 patients and used questionnaire developed in the English then translated to Urdu. Face to face interviews was used to collect respondent’s opinion. Reliability was tested using Cronbach’s alpha where regression was used in analyzing data with the aid of SPSS. The study established that all healthcare services significantly and positively affected patient’s satisfaction where prenatal services contributed more to patient satisfaction. This study also noted that physical behavior of healthcare workers moderated the effect of healthcare services on the patient satisfaction. This study focused on three services aimed at enhancing patient satisfaction of three health facilities in Pakistan. The study findings indicate how Pakistan government has put in place service delivery policies that have significantly enhanced patient satisfaction. This also means that the right to healthcare such as availability, affordability and accommodation are all meant to enhance patient satisfaction thereby promoting and protecting the right to health. Even though the study indicated positive significance to patient satisfaction which may allow generalizability in public hospitals in Pakistan, the case may be different with the Kenyan health environment. The current study sought to investigate how government policy is enhancing service delivery to ensure protection and promotion on the right to health. It also targeted Machakos County hence    offered a broad scope necessary for generalization. This study also focused on multiple stakeholders hence addition of outpatients and incorporated questionnaire and interview to establish if there was any positive significance on state obligation to protect and promote health.

Mohamad and Murad (2017) did a study on quality healthcare services of public and private healthcare in the United Arab Emirates. Using pilot research, service delivery questionnaire’s applicability was confirmed resulting in an acceptable threshold Cronbach alpha of 0.87. The questionnaire was handed out to 150 responders in the city and surrounding areas of Abu Dhabi. The target audience were between 18 and 65 years, in line with the demographic parameters. Duly     completed forms were returned where one was not complete hence 149 utilized in the study. The study showed that the effort that a healthcare institution puts in delivering healthcare affects the trust of the public when seeking healthcare services. The study also found a huge difference in health service delivery between public and private hospitals as they are not primarily focused on making profit hence are less interested in maintaining clientele. Additionally, because the majority of services are free, customers are less concerned with subpar customer service. Private hospitals however, prioritize providing excellent customer service in an effort to keep their clients. They make significant investments in the newest machinery to guarantee that the anticipated therapeutic outcomes are realized. The study recommended that while the government is able to continue its subsidies, the superior way of operations used by private hospitals should be implemented to enhance the services and increase customer satisfaction. The fact that only a limited number of people who were restricted to the region in and around Abu Dhabi took part in the survey is one of the study’s significant drawbacks (Murad, Mohamad, et al., 2017). This study increased the number of questionnaires distributed to investigate service delivery in all public hospitals in Machakos County and determine the ways that the government can adopt new technologies and ways of delivering services in public to protect and promote the right to health. The information gathered served as a sound foundation for the development and implementation of an ongoing, successful policy in Machakos County, Kenya.

Achimugu et al., (2013) did a study to compare government efforts and expectations of the people in Nigerian Ofu Local Government’s service delivery. The study sample size consisted of 61 respondents identified through judgment sampling technique and stratum for adequate representation and their knowledge of the matter. The strategy of using questionnaires was employed for data collection. Analysis conducted at the end of the survey revealed that 61 questionnaires were distributed and were successfully retrieved. The study showed that speed and efficiency of local government were rated very poorly. The findings established that corruption, reduced speed in administrative processes, low employee morale as well as absence of accountability contributed to ineffective service delivery in the Ofu local government. This study suggested that proper and transparent means are needed to hold the government responsible. They also pointed out that these issues hindered the delivery of services to the people, especially in the healthcare department with medical professionals quitting and striking

(Achimugu et al., 2013). One of the drawbacks of this study is that it didn’t account for the lack of funds. The study targeted the health delivery policies in the County that can help all the workers in the hospitals to perform better in the quest to protect and promote the right to health.

METHODOLOGY

The study used descriptive cross-sectional research design to describe phenomena under investigation. Descriptive cross-sectional research design enables the researcher to observe things the way they are thereby describing behavior, attitude and events as they happen (Pawar, 2020). The design helped in planning all activities in the research process such as data collection and trends in the data to make interpretations as well as understanding the relationship between variables (Robertson, 2018).

Data Presentation Analysis and Discussion

Healthcare Access and Service Delivery in Machakos County

This study observed that the rollout of universal health coverage in Machakos County was poised to have far-reaching impacts on health care access and service delivery in the county. In this study, access to healthcare was measured by multiple parameters broadly encompassed into three categories of individual, structural, and systemic factors (Tzenios, (2019). These factors constitute status of health facilities, number of or availability of healthcare facilities, patient-doctor ratios, distance covered to access medical care (geographical/environmental factors), among others. Two pf these parameters i.e. state of health service delivery and strategies for improving service delivery are examined in this study.

State of Health Service Delivery in Machakos County, Kenya

This study sought the views of patients and healthcare practitioners on the state of health service delivery in terms of five variable. First is the speed at which health services were provided. Secondly, availability of innovative healthcare technologies. Thirdly, availability of skilled healthcare workers. Fourthly, was the presence of frontline workers and finally, whether healthcare facilities exceeded expectations. The results of the data analyzed is presented in figure 1and Figure 2 which shows the views of patients and health workers respectively.

Figure 1: Views of Patients on Health Service Delivery in Machakos County, Kenya

From figure 1, first, 53% and 9% of the patients agreed and strongly agreed that there was good speed at which health services were provided while 27% and 6% disagreed and strongly disagreed respectively. Secondly, 34% and 6% of the patients in Machakos County agreed and strongly agreed that there was availability of innovative healthcare technologies in the County Health facilities. Thirdly, 68% and 20% of the patient agreed and strongly agreed that there were skilled healthcare workers in Machakos Public Health facilities. Fourthly, 55% and 8% of the patient agreed and strongly agreed that healthcare facilities exceeded expectations. Machakos Public Health facilities. Finally, 49% and 39% of the patients disagreed and agreed that presence of frontline workers in Machakos Public Health facilities

From this data it appeared that the patients rated health service delivery in respect to the facilities they frequented for medical attention. This indicates that there has been efforts to ensure facilities have qualified and skilled health professionals. However, the County is not fully resourced with skilled health workers in all facilities. Some of the centers are considered to have unskilled or semi-skilled healthcare workers. This position is supported by findings that in some of the health stations the study interviewed health care workers who were not trained for providing health services at a level 2 facility. There were community health assistants and community health volunteers manning these health facilities. This raises the chance of misdiagnosis, mis prescription, unreliability and low-quality service delivery. With this situation of unqualified/unskilled health workers in the health centers, it is next to impossibility to provide quality healthcare that is affordable as required by UHC program. It means patients are forced to seek health services from private health facilities, exposing them to extortion through exorbitant consultation fees, quacks taking advantage of the situation, and high chances of misleading health directives in quest to make money for the private clinics.

On availability of innovative health care technologies within the facilities that increases health experience, participants were in disagreement. The majority 49% observed that there were no such technologies within the facilities, with 5% strongly disagreeing with the statement. These aspects impacted on health care service delivery. This could be partly confirmed by the 27% and 6% patients who disagreed and strongly disagreed respectively that there was good speed in the provision of healthcare service at the facilities. Although the majority 53% and 9% agreed and strongly agreed correspondingly on service provision being done at a good speed. These results were consistent with the findings by Wanjau, Muiruri, and Ayodo, (2012), whose findings revealed that low capacity of employees and inadequate adoption of innovative health technologies negatively affected health service delivery by a factor of 0.981 and 0.917 respectively. According to them, this contributed to low rates of patient satisfaction and poor quality of health services.

In regards to evaluation of health care services in terms of meeting expectations, 31% and 2% of patients respectively disagreed and strongly disagreed on the quality of health care service exceeding their expectations. This was however contrasted by a majority 55% and another 8% who agreed and strongly agreed on healthcare service delivery exceeding their expectations respectively. We deduce from these patients that health care service delivery within medical facilities across Machakos County has significantly improved. Potentially, this is influenced by health policies as championed by UHC program. It could be adduced that UHC program has to a notable extent positively impacted on the provision of healthcare services across the county, at least as per the opinions of the patients who participated in the study

Further, a significant portion of sample observed the absence of enough frontline staff in the health facilities. Actually, 7% strongly disagreed with the statement that there is enough frontline staff in the health facility, with a resounding 49% others disagreeing with the statement in toto. However, 39% of patients indicated that the frontline staff in health facilities were enough, as did 5% others who strongly agreed on the availability of enough frontline staff. The majority were of the opinion that frontline staff are inadequate and hence an indication of potential delays before one could be consulted due to staff shortage related issues. Despite this, the facilities are considered to have qualified health practitioners. Analysis shows that 20% of patients and a resounding 68% others strongly agree and agree respectively that the facilities have skilled healthcare workers. This accounts for 88% of all patients, an indication that the facilities have resourceful healthcare workers. Even then, some 9% observe that the facilities lack skilled health care workers, something echoed by 1% others who strongly supported this position.

Reflecting on more or less similar issues related to health service delivery in Machakos county including: speed at which health services were provided, availability of innovative healthcare technologies, availability of skilled healthcare workers, the presence of frontline workers and finally, whether healthcare facilities exceeded expectations, the health professionals had mixed feelings, with majority agreeing to most of the issues raised by the study in effort to understand the status of health service delivery in the county. Their ideas are shown in the following figure.

Figure 2: Health Practitioners’ Views on Health Service Delivery

From figure 1.2, majority of the health care professionals indicated that they have witnessed significant improvements in health service delivery over the last five years. These comprised of 23% who strongly agreed and 57% others who agreed that delivery of health services had significantly improved in the five years, coinciding with the timeline when UHC was launched for piloting in the county. Even then, some 16% others disagreed and another 2% strongly disagreed with this point. They did not clarify whether the delivery of health care services had stagnated or dwindled in the specified period, but they do not consider any noticeable improvements overtime.

They also observed in their majority that the facilities had skilled healthcare workers, echoing the patients. However, in this case, they resoundingly reported the presence of skilled health workers, where 38% strongly agreed and another 52% agreed on availability of skilled healthcare workers in facilities within the county. Just a few of health professionals, 8% and 2% who disagreed and strongly disagreed accordingly on availability of skilled healthcare workers in the facilities. Further, the study found that the health care workers were hardly enough to serve the communities where these facilities were situated. According to health professionals, only 17% of them believed that the healthcare workers were enough. This was contrasted by majority 58% who disagreed and another 23% who strongly disagreed on availability of enough healthcare professionals within the health centers in the county. This explains the fact that unqualified workers in community health assistants were at times providing health services in some of the facilities, almost all level 2 facilities were manned by one health professional, if s/he was off duty or on an assignment in a different Centre, health delivery was completely unavailable in most of these facilities. The Medical Officers of Health (MOH) interviewed in each sub-county, decried the level of understaffing many facilities. They observed that there was only one health care professional in all level 2 facilities, all Level 3 were understaffed, as were all Level 4 and Level 5 facilities in the county. In fact, some staff members served in two facilities, alternating on the days of the week for the facilities to remain open and functional.

Adoption of innovative technologies are critical in health service delivery, increasing accuracy in diagnosis hence enhanced and quality service for patients. Technologies also ease labor duties for health professionals, making work easier for them. This was therefore a key consideration for the study to be able to determine the status of health service delivery in the county. Regrettably, just 2% and 31% of health professionals who respectively strongly agreed and agreed that there were innovative technologies for enhanced health service delivery in their respective facilities. Worryingly, majority 55% disagreed and another 7% strongly disagreed on presence of these technologies. This implied less adoption of innovative technologies in health service delivery, with potential to negatively affect the quality and speed of health services within facilities. Additionally, the facilities had to refer patients to other medical centers where such technologies were adopted. The study established that 83% of all health professionals who observed the presence of innovative technologies were domiciled in level 3, Level 4 and Level 5 facilities. Just 17% were providing services at Level 2 health facilities across the county. This indicates the high rate of referrals incase specialized treatment of patients was needed. It inadvertently hampered health service delivery, and access to the desired levels.

Despite the considered absence of innovative technologies by health professionals, just as reported by patients, the facilities provided enhanced quality healthcare services to patients. This according to 58% of health professionals and another 19% who strongly agreed that the service delivery at their stations was of enhanced quality. There were just a few who dissented, 20% disagreed and 2% others strongly in disagreement on provision of enhanced quality health services in their facilities. This position is perhaps strengthened by the 4% who strongly disagreed and 30% others who disagreed on the speed of service delivery being good. This implied the speed of service delivery was low. Although this position was in contrast to the majority 52% and 8% health professionals who correspondingly agreed and strongly agreed that the speed of service delivery was good in the facilities they operated from.

It was established that these mixed positions were perhaps attributed to the rollout of UHC within the county, which did not cover all health facilities. To determine if UHC had impacted on health service delivery, the health professionals agreed and strongly agreed in their numbers. Those who agreed that UHC had contributed to improved health service delivery in their facility were 52% while those who strongly agreed were 15%. These majority did not however silence the position of 24% and 3% health professionals who disagreed and strongly disagreed with their positing. Their considered opinion is that UHC has not had any notable contribution to improved quality of health service delivery in the county. The majority of those who strongly disagreed were in Level 2 facilities, located further in the interior of the expanse county. Strangely though, a majority of those who disagreed that UHC had positively impacted on the quality of health service delivery were in Level 3 and Level 4 facilities. Explaining that UHC was not rolled out in all facilities in the county, and hence its impact was not yet significant in the delivery of healthcare services in majority of the facilities spread across the county.

The overall conclusion is that UHC had contributed to service delivery, albeit to an extent. It is deduced that patients and health professionals alike don’t realize any significant gains from the piloting of UHC and other health policies in the county. There is need for interventions to address glaring gaps that hinder service delivery.

Strategies for Enhanced Healthcare Service Delivery

The study had afforded the participants opportunities to provide solutions to challenges on health service delivery in the county, particularly in respect to their facilities. The following table indicates the 28 proposed solutions to attain effective healthcare service delivery in Machakos County and how the study participants rated them.

Table 1.3: Strategies for Enhanced Healthcare Service Delivery in Machakos County

From table 3, the majority of the respondents approximately 39% indicated that recruitment of more healthcare workers was the best strategy for enhancing delivery of health care in the County. Improving on infrastructure came second with 11%, provision of equipment to improve on service delivery was third with 10% same to enhancing modern medical technology which also attracted the opining of 10% of the respondents. Other measures including, provision of medical supplies, hasten speed of healthcare service delivery, facility efficiency, expanding service offered, continuous health staff training and capacity building programs, addressing governance issues of health services, having motivated healthcare workers and timely delivery of medical supplies as well as upgrade facility to a higher level attracted between 3% and 0% as shown in table.

Both patients and healthcare professionals were heavily concerned with inadequate human resources within the health facilities. This hampered efficient and effective service delivery, as did poor state of infrastructure, absence of equipment and inability to adopt modern technology and absence of timely and adequate medical supplies. A sneak preview of the issues in details supported the earlier findings on these specific parameters. The facilities had inadequate healthcare workers, they were deprived of qualified health specialists, there were unavailability of doctors, pharmacists, clinical officers, and nurses. Most of the facilities were understaffed, and especially Level 3 Level 4 and Level 5 facilities. The situation is worse in instances where services are provided by community health assistants, who are reported to be inadequately trained, hence unqualified to provide healthcare services, especially at a medical facility. This is common in Level 2 health centers across the county. The massive staff deficiencies resulted to overcrowding within facilities, paralysis of service delivery, and low rate in service offering, limited services availability. This negatively impacts on the quality and speed of healthcare service delivery.

In regards to infrastructure, facilities were reported to be lacking key utilities such as water and reliable energy sources. Further, most of the facilities did not have enough structures such as wards, theater and ultra-sound X-ray rooms, maternity wings, laboratory units among others as noted by the respondents. Some structures within medical facilities had stalled while others were overdue for renovations. There were instances where a single building with few inadequate rooms was all the facility had, hampering any chances of better health service delivery. Some facilities had closed down for broken pit latrines, which forced residents to walk long distances to the next available facility for medical attention. The respondents decried the absence of key medical equipment. Laboratories were without equipment’s, there were no theater facilities in most of the facilities, and especially level 3 and level 4 facilities, which resulted to referrals even for minor surgeries. The facilities lacked modern technology, innovation and equipment. This affected the rate and quality of service delivery.

To address challenges in service delivery, patients and health care professionals proposed recruitment of qualified healthcare workers/professionals, including medical specialists, pharmacists, lab technicians, clinical officers, and doctors and nurses within the facilities. This was a call that accounted for 35% of all proposed solutions, appearing 39% in the case of health professionals and 31% by patients. At 10% apiece, respondents called on the authorities to improve on infrastructure and provide medical equipment within the health facilities.

Infrastructure development included construction of buildings to host health facilities, construction of additional buildings within facilities to provide expanded services, and even upgrade facilities to a higher level reported as part of the solutions to enhanced healthcare service delivery in the county. It also constituted renovation of existing structures hosting medical facilities, and construction of support facilities. The new infrastructures proposed were mainly support facilities and included wash facilities, boreholes/water connection pipes/harvesting systems, electricity connection, laboratory units, maternity units, ultra-sound rooms, and chemists (pharmacy). Equipment included ICT equipment, laboratory equipment, theater equipment, and x-ray equipment. These were considered essential to better service delivery, reported 10 and 9 percentage times of all solutions reported by health professionals and patients respectively.

Embracing modern medical technology included adopting technology and innovation in service delivery. The respondents reported the need to use computers and software for registration of patients to hasten the speed of the process. Computers and software were also needed to easily retrieve health records/data for patients, eventually affording a wow customer experience. Adoption and use of biometrics were considered a better way to fast-track medical service delivery for patients, by both health care professionals and patients. Technology was reported as critical in enhancing healthcare and service. Modern laboratory, x-ray, and theater equipment, among others were considered critical to excellent diagnosis and provision of quality health services.

Provision of medical supplies was reported as a notable solution to enhanced service delivery within medical facilities in the county. This accounted for 5% overall rating of all reported solutions. It combined with the need for timely delivery of medical supplies which was reported at 2%. These two proposals were synonymous. The objective was to ensure the health facilities had adequate medical supplies at all times. This would translate to reliability and trust in the healthcare system. It would also promote efficiency in healthcare service delivery within the facilities. Medical supplies are at the heart of healthcare service delivery and hence the noted emphasis by both healthcare professionals and patients, to the extent of considering them two separate solutions. Medical supplies constitute drugs, surgical, hospital consumables and others.

Additionally, the proposals comprised of increased speed of healthcare service delivery, expanded service catalogue within the facilities, continuous training and capacity building for healthcare workers and professionals, and enhanced performance and efficiency of UHC to bring medical services to affordability and coverage of all residents/patients.  Governance issues were hampering effective service delivery hence a call for them to be ironed out. These were reported at the hospital level, county and national levels. The proposed solution focused on providing quality leadership at the hospitals level, and addressing health system functionality issues at the county and national level. This included funding of health programs, creation of new facilities, equipping of facilities, human resource allocation and deployment, staff motivation, facility reclassification and upgrading to a higher category for expanded service offering among others.

Other recommendations included rolling out UHC in Machakos County, that is to all facilities across the County, monitoring and evaluation of service delivery, improving the quality of healthcare service at facilities, strengthening of the healthcare system to improve access to primary healthcare, improving accessibility to health facilities by availing ambulance, improving condition of roads leading to facilities and locating facilities near to peoples; providing medical services for free, constructing more health facilities, and addressing nepotism and corruption within the healthcare system across the county.  The participants were convinced that implementing these proposals would contribute to enhanced and efficient healthcare service delivery in the county.

CONCLUSION

The findings of this study clearly point out the success and failures of UHC rollout in Machakos County. The failures stem from UHC having been rolled out to Machakos Level 5 Hospital only, and thus leaving a majority of the county population at the clemency of the national legislation with minimal healthcare benefits to citizens. It can be deduced from the findings that health service delivery continues to suffer a great deal. The major issues impacting health service delivery include unreliable service delivery, unaffordable healthcare services, inaccessible health facilities, poor infrastructure facilities, underfunding of health sector and governance issues. Specifically, the health service delivery within the county is unreliable owing to staffing issues. The county has experienced untimely and frequent labor strikes by health professionals who are demoralized due to underpayment.

The state of health service delivery in Machakos County is gradually progressing. Significant steps are being implemented that have witnessed improved health service delivery to residents in the recent period. These include the installation of new health centers, and efforts to equip facilities with drugs, medicines, equipment and human resources. Other efforts have been attempts to increase budgetary allocations to health facilities. Nonetheless, the speed and quality of health service delivery is rated as poor owing to the multiple under-functionalities of the sector. Facilities are unsupplied in a timely manner with the vital medical supplies and equipment for their effective operations. Additionally, the cost of healthcare services is too high for residents with meagre monthly incomes. Accessibility and affordability of health services do not promote equity, only the rich are able to commute quickly for emergency situations since they can afford private transportation means and private medical care, unlike the majority masses.

RECOMMENDATIONS

The study recommends actions to address health service delivery challenges that hinder Machakos County residents from enjoying their right to health in full as by law required. The implementation of UHC was at pilot level, it is recommended that UHC is rolled out in the entire county, serving residents and patients in all facilities across the county. This comes along with increased funding and availing of affordable health insurance schemes that have been incentivized for residents. The roll out of SHA to replace NHIF could be the solution to health insurance schemes that have remained unaffordable. However, the main agenda is to ensure SHIF is effective and functional and it indeed is affordable to residents while attending to all healthcare cost needs and bills within health facilities.

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