Assessing the capacity of primary healthcare facilities and healthcare workers in managing diabetes and hypertension in Kisumu county, Kenya

Abstract

Background: The burden of non-communicable diseases (NCDs) like hypertension and diabetes is rapidly increasing in sub-Saharan Africa, with cardiovascular conditions contributing to about 40% of all NCD-related morbidity. The increase poses considerable challenges, including governance, prevention of risk factors, monitoring, surveillance, and evaluation of health systems. In Kenya, NCD-related mortality is approximately 600 per 100,000 for males and 500 per 100,000 for females, with Kisumu County reporting approximately 1,118 per 100,000 populations annually, compounded by a high HIV burden. Primary healthcare (PHC) provides essential care that could ensure proactive, patient-centered, community-based, and sustainable care to prevent and manage NCDs, yet its implementation remains weak with large regional and subnational differences.

Methods: This mixed-methods study was conducted between October 2023 and September 2024 in Kisumu County, Kenya, and included a facility assessment survey, PHC worker surveys, and focus group discussions (FGDs) with 20 patients living with DM and/or HTN. Ten facilities out of 29, classified as level 2 to 4 under the Kenya Essential Package for Health (KEPH), were purposively selected for the study. The evaluation assessed service availability and performance in NCD care using the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) toolkit. Key aspects included essential drugs, guidelines, equipment, patient follow-up, counseling systems, support supervision, and the training, knowledge, perceptions, and practices of PHC workers.

Results: While most facilities conducted routine DM and HTN screenings, only 20% of them had visible national guidelines, indicating a significant policy-implementation gap. Over 80% of PHC workers had not received post-basic training in DM and HTN management, and only 50% were proficient, with an average knowledge score of 2.2 out of 4. Nearly 80% [95% CI: 49.0%, 94.3%] of facilities referred patients to higher-level facilities due to inadequate clinical capacity or a lack of essential medicines. Patient follow-up and counseling on self-care and lifestyle changes were rated poorly, averaging 2.9 [95% CI: 1.4, 4.4] out of 6. A qualitative study through FGDs revealed frequent medication shortages, a lack of basic equipment, and insufficient patient information on self-care, diet, and exercise.

Conclusions and recommendations: Significant gaps exist in the organizational and workforce capacity of PHC facilities in Kisumu County, Kenya. Addressing these modifiable issues requires targeted strategies and investments to scale up effective interventions. Priority areas include expanding training programs for PHC workers in NCD management, particularly diabetes and hypertension, tailored to local and linguistic contexts, improving infrastructure to support individualized counselling and follow-up, and strengthening the integration of community health promoters (CHPs) to bridge communication gaps and improve continuity of care. This could proffer far-reaching implications for health outcomes and overall health system efficiency.

Keywords: Communication gaps; Guidelines; Health system; Mixed methods; Patient follow-up; Referrals.

Fig. 1

Flowchart depicting the general sampling strategy for the mixed-methods study conducted in Kisumu County, Kenya, between 2023 and 2024.