Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya

Background: Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi's equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya.Methods: We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach.Results: Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date.Conclusions: If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity