Investigators and Institutional Affiliation

Name	Role	Affiliate Center
Dr. Prisca Otambo	Principle Investigator	Center for Public Health Research
Dr. Joseph Mutai	Co-Investigator	Center for Public Health Research
Mr. James Kariuki	Co-Investigator	Center for Public Health Research
Mr. Ismail Adow	Co-Investigator	Center for Public Health Research
Mr. David Mathu	Co-Investigator	Center for Public Health Research
Mr. Erastus Muniu	Co-Investigator	Center for Public Health Research
Ms. Sarah Karanja	Co-Investigator	Center for Public Health Research
Mr. Rodgers Ochieng	Co-Investigator	Center for Public Health Research
Mr. Philip Ndemwa	Co-Investigator	Center for Public Health Research
Dr. Judy Mwai	Co-Investigator	Center for Public Health Research
Mr. Steve Onteri	Co-Investigator	Center for Public Health Research
Ms. Lucy Magige	Co-Investigator	Center for Public Health Research
Ms. Schiller Mbuka	Co-Investigator	Center for Public Health Research
Dr. Zipporah Bukania	Co-Investigator	Center for Public Health Research

ABBREVIATION AND ACRONYM

ANOVA	Analysis of Variance
CBHI	Community Based Health Insurance
CHW	Community Health Workers
CHV	Community Health Volunteers
CHUs	Community Health Units
CSR	Cooperate Social Responsibility
DEFF	Design Effect
EDA	Exploratory Data Analysis
FGDs	Focused Group Discussions
GoK	Government of Kenya
IQR	Interquartile range
ICF	Informed consent form
IDIs	In-Depth Interviews
KEMRI	Kenya Medical Research Institute
KII	Key Informant Interview
LMIC	low- and middle-income countries
MCH	Maternal and Child health
MoE	Ministry of Education
MoH	Ministry of Health
NACOSTI	National Council for Science and Technology Innovation
NGO	Non-governmental Organization
NHIF	National Hospital Insurance Fund
ODK	Open Data Kit
PLWD	Persons Living with Disabilities
SDG	Sustainable Development Goals
SDGs	Sustainable development Goals
SERU	Scientific Ethics Review Units
SE	Standard Error
SPSS	Statistical Package for Social Science
RAs	Research Assistants
RSE	Relative Standard Error
UHC	Universal Health Coverage
UN	United Nations
WASH	Water, Sanitation and Hygiene
WHA	World Health Assembly
WHO	World Health Organization
WRA	Women of reproductive age

OPERATIONALISATION OF TERMS

Community: a social group of any size whose members reside in a specific locality, share government, and often have a common cultural and historical heritage.

Implementation research: a scientific inquiry into questions concerning implementation—the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions).

Health (service) providers: Institutions or professionals who are accredited or licensed to practice health care under existing laws. Examples are hospitals and clinics and health care professionals such as doctors, nurses, medical staffs, counsellors, psychologists, and the likes

Influencers: Are power players who advocate for better health and wellbeing, put through policy proposals, cause ideological changes, and affect popular perceptions.

Policy implementers: a wide range of people and organisations that can be involved in policy implementation, depending on the level of enactment (from local to national) and the type of policy (from regulation to statute).

Social innovations: includes but not limited to the development of products, services, models, programs and entrepreneurship.

Universal health coverage: means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. 

Abstract

Introduction: The current global, regional and national emphasis on universal health coverage (UHC) has created a supportive environment for health innovations, interventions and heightened private sector engagement. These new changes are geared towards accelerating attainment of UHC. Consequently, the scaling-up of promising health innovations and interventions in low- and middle-income countries is becoming an increasingly important area of interest for stakeholders seeking to build efficient, resilient and adaptive health systems. Water, sanitation and hygiene (WASH) either at a health facility or community level underpins safe and quality service provision for achieving UHC. Overall, acceleration of UHC will require a shift from single stand-alone interventions to integrated multi-faceted approaches which are brought about by newer health innovations and interventions. It is postulated that the current traditional, silo healthcare service delivery models have failed to deliver effective and better health programs outcomes. Thus, there is need to conduct implementation research studies regarding these “promising” health innovations and interventions so as to provide evidence to support scaling-up and sustainability in low resource setting.

Objective: To assess anticipated accessibility and acceptability of accelerateUHC (3-in-1), an intervention package for accelerating UHC attainment.

Methodology 

Study Design: A convergent parallel mixed methods study design i.e. combining quantitative and qualitative methods in parallel at data collection and analysis.

Study Area: Kitui County which has 2 important features namely arid-and-semi arid lands (ASAL) as well as agricultural highland which are important conditions for this implementation research.

Target Population: The study will target different population groups.

Data Management: For the quantitative part of the study, a questionnaire will be employed which will provide proportions on anticipated accessibility and acceptability of the proposed package. Quantitative data capture will be captured using tablets. 

Qualitative Component: Focus Group Discussion will be conducted among the general population groups including:  women of reproductive age, youth, and elderly persons drawn from the community health units and CHVs in the sub counties selected. The CHVs will be approached to identify the communities. Additionally, in-depth interviews (IDIs) and key informant interviews (KII) will also be conducted among opinion leaders.

Ethical Approval: The study sought for and received approvals from KEMRI Scientific Ethics Review Unit (SERU) and the National Council for Science, Technology, and Innovation (NACOSTI). Informed consent will be sought from all eligible participants.

Expected Application of the Research Findings: The findings of this survey will be instrumental in continuing the adaptive learning of what works as well as informing accelerateUHC’s scale-up program in in Kenya and beyond.

Duration of the Project. Now that SERU and NACOSTI have approved the study, it is expected that the project/study will take approximately 6 months.  

Budget: This implementation research is estimated to cost Kenya Shillings 12,698,890/= (twelve million, six hundred and ninety  eight thousand, eight hundred and ninety shillings).

Lay Summary

Introduction: There are new approaches in the way health services are being provided by governments all over the world. These new approaches are geared towards accelerating attainment of universal health coverage (UHC). Some of the new approaches include innovations and interventions which have not been tried before. Water, sanitation and hygiene (WASH) component is an important program since it affects safety and quality of health. Overall, to make sure all citizens in any given country have quality health care which they can enjoy, there are discussions of combining two or more promising health innovations and interventions. The question that research scientists will attempt to answer is – with all these promising innovation and interventions, will the community accept them? Do they meet the health requirements of the community? If they fail to work, what are the reasons for the failure? If they have to be implemented to the rest of country, how should Ministry of Health proceed? The aim of this study is find out from the local communities in Kitui County, whether accelerateUHC, the proposed health intervention package, is acceptable to them and how it can be made sustainable.  

How the research is going to be undertaken: The team will use a scientific method called ‘mixed study’, which involves having community group discussions as well as individual interviews. The study team will interview heads of household, community leaders, MoH personnel, chiefs, school head teachers as well as water resources management committee members. The research team will ask a set of questions and record the answers using Tablets or Smartphones. For community group discussions, the team will use tape recorders to record the discussions. Later, the research team will type all the meeting discussions in a computer ready for analysis and interpretation. 

Permission to conduct the study was sought from, and granted by, KEMRI’s Scientific Ethics Review Unit (SERU) and the National Council for Science, Technology, and Innovation (NACOSTI). All the community members will also have to either agree or disagree to take in the research as requested by the research team. 

There will be benefits to local residents of Kitui County and the entire country. The research information will help inform RaHa Solutions on the best method of providing to the people Kitui County free medical services as well as safe drinking water for the community. In addition, girls Kitui County schools will receive re-useable sanitary pads. 

The lessons we shall learn from this survey will help inform RaHa Solutions on how to offer the same services to other counties of Kenya and other countries.

Once the study starts, it is expected that the project will take approximately 6 months to complete. 

This implementation research is estimated to cost Kenya Shillings 12,539,390 (twelve million, five hundred and thirty nine thousand, three hundred and ninety shillings).

Introduction

Global Overview of UHC

The focus on Universal Health Coverage (UHC) gained momentum in recent years when the World Health Assembly (WHA) and the United Nations (UN) General Assembly called on countries to accelerate transition towards universal health access through affordable and quality healthcare services (World Bank, 2019). The strategic aim of UHC is to ensure that all people have access to the needed health services; that the services are of sufficient quality and thus effective; and also ensuring that the use of these services does not expose the user to financial hardship. The UN – General Assembly joint communique also called for the need to supplement efforts towards improving revenue generation efforts so as to reach the most basic level of coverage.  This would ensure populations move away from out-of-pocket spending to reliance on compulsory prepaid funding sources (WHO, 2018).

Good health is one of the pillars of human development for it enables people to pursue their education, personal and professional goals. Thus contributing towards poverty alleviation and reducing socioeconomic inequity (Tangcharoensathien & Palu, 2015).    Achieving UHC would thus enable citizens afford the right to health throughout their life course (WHO, 2014). Empirical studies have documented that people living in countries that have achieved UHC tend to have longer life expectancy at birth and healthier life expectancy than those just implementing UHC (Ranabhat et al., 2018). UHC has benefits that go beyond health. High out-of-pocket costs can lead to catastrophic health expenditure and impoverishment (World Bank & WHO, 2017).

UHC is listed as Target 3.8 of the Goal 3 out of the 17 Sustainable Development Goals (SDGs) with a focus on a health-related target (Hogan et al., 2018). In addition, it has been heightened as a critical yardstick for countries to measure and track progress toward achievement of the SDGs (Gera et al., 2018). Good health is thus an outcome of many factors beyond health service provision; and investments in health contribute to the broader development progress of a country.  Health is therefore, considered central to the attainment of SDGs (WHO, 2017).  

Accelerating attainment of UHC                                     

Arising from synthesis of literature, conference proceedings and primary data is suggestion that UHC remains a major international challenge and a number of countries are not on track to achieve coverage by the year 2030 with some finding even the initial gains difficult to sustain (Tangcharoensathien & Palu, 2015). This situation calls for novel approaches on multiple fronts, including technology to improve efficiency, affordability, and access; innovative financing models; and reorienting systems around primary health care, along with a workforce equipped to deliver these new promising models.

The current global, regional and national emphasis on UHC has created a supportive environment for health innovations, interventions and heightened private sector engagement. The scaling of promising health innovations and interventions in low- and middle-income countries (LMICs) is becoming an increasingly important area of interest for stakeholders seeking to build efficient, resilient, and adaptive health systems. 

Since the year 2015, countries around the world have been working towards achieving the SDGs in the context of health with the aim of meeting the target of UHC established under SDG 3 (Chapman, A. R., 2016). This has led to an exponential growth in health innovation and intervention supply. Some of the promising innovation and interventions that act as a catalyst for acceleration of attainment of UHC are outlined as follows:

a) Alternative financing models to complement tax-based medical insurance schemes. Many countries are struggling to raise the financing required to move closer to UHC. Finding new sources of financing to reach and sustain UHC is critical. In addition, there is a call to prioritise domestic healthcare spending across different products and services.

b)    Shift to integrated multi-faceted approaches as compared to traditional, silo models of care which are failing to deliver effective and better health programs outcomes for integrated and person-centered care (OECD 2016; Kruk et al., 2018). Fragmented health delivery care models and lack of well-developed primary care are well documented. There is evidence of low level of inter-sectoral collaboration (i.e. water, education, public works sectors) at the community level to affect health promotion. Novel approaches are required to integrate primary health care (PHC) with other service sectors so as to adopt a less hospital-centric approaches.

c)   Reasons for countries which are lagging behind in attainment of national UHC targets could possibly be explained by among other factors, the limited utilization of innovations and technology. There are suggestions that for these countries to progress more quickly, they could explore innovative technology. Innovation opportunities are not only in hard technology but also in “social innovation” and finding home-grown solutions in customizing existing digital platforms (McClellan et al., 2020). Therefore, scaling up technologies to make a significant impact requires paying equal attention on innovations in business models, care processes, pathways, and products. Ensuring that technology is affordable to low-income countries through innovative partnerships.

Linking WASH Program and accelerating UHC

Water, sanitation and hygiene (WASH) either at a health facility or community level underpins safe and quality service provision for achieving UHC. The linkage between WASH program and primary health program (UHC by extension) to offer safe health delivery, leads to improved quality of care and infection prevention control (WHO, 2020). Thus, it is imperative that every household and healthcare facility have safe and reliable water, sanitation and hygiene facilities all working towards attainment of UHC. Thus, adequate and resilient WASH services are essential for any outbreak prevention, preparedness and control at household, community, county and national levels.  Empirical studies have estimated that nearly 844 million people do not have access to basic source of water while 2.3 billion people do not have access to a basic sanitation service. It is also estimated that 10% of the global burden of disease results from unsafe water, poor sanitation or inadequate hygiene (Abu et al., 2019). The Sustainable Development Goal 6 target 6.2 aims to “achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations”(UN General Assembly, 2015). 

Provision of water and sanitation plays an essential role when it comes to protecting human health during all outbreaks. According to WHO, good and consistently applied WASH practices, both in health care settings and community are key to prevent person to person transmission of many infectious diseases. Improving sanitation is therefore key to achieving the health related Sustainable Development Goals (SDGs) of reducing child mortality and combating diseases (Boschi, 2008 & UN, 2011). Poor status of WASH and related interventions can impact growth and development of children in multiple ways (Sire et al, 2013) and there is consensus that improvement in health would not be possible without improving WASH conditions of underprivileged children around the world.

Kenya’s Progress towards attaining UHC

Kenya has made progress towards Universal Health Coverage as evidenced in the various policy initiatives and reforms that have been implemented in the country since independence (Okechet al., 2015) with support of various stakeholders. The main objectives towards achieving UHC in Kenya include: Progressively increase the percentage of Kenyans with coverage for essential health services; Increase the percentage of Kenyans covered under prepaid health financing mechanisms such as health insurance, subsidies and direct government funding to access health services; Progressively expand the scope of the health benefit package accessible to all Kenyans; Improve the quality of health services; Protect Kenyans from catastrophic health expenditures, in particular the poor and the vulnerable groups; Provide and retain health resources appropriate for the delivery of health services; Strengthen the leadership and governance within the health sector (UHC, 2018-2022).

Based on the empirical studies, about half of Kenya’s population  do not have access to standard healthcare services, and a third of them are not protected from the harmful effects of out of pocket healthcare payments in 2013 (Mwaura, 2015). It could be argued that current reforms are therefore halfway through national UHC journey. Different scholars and think tank groups have recommended that Kenya should reorient its health financing strategy away from a focus on contributory, voluntary health insurance, and instead recognize that increased tax funding is critical and rethinking benefits package for sustainability (Barasa, 2013). Additionally, and on the global view, it is estimated that 844 million people do not have access to basic source of water while 2.3 billion people do not have access to a basic sanitation service. It is also estimated that 10% of the global burden of disease results from unsafe water, poor sanitation or inadequate hygiene (Abu et al., 2019).  The SDG # 6 target 6.2 aims to “achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations” (UN General Assembly, 2015). According to a joint monitoring programme report of UNICEF and WHO (WHO, 2017), just over half of the population (58%) of Kenya have access to drinking water from improved sources with less than 30 minute round trip to fetch water (UNICEF & WHO, 2017). Provision of water and sanitation plays an essential role when it comes to protecting human health during all outbreaks. According to WHO, good and consistently applied WASH practices, both in health care settings and community are key to prevent person to person transmission of many infectious diseases.

RaHa Solution Global Program 

RaHa Solutions is a global humanitarian organization whose primary mission is to build an inter-continental network of people that create new ways to finance UHC acceleration programmes (RaHa website, https://www.raha.solutions). Its main mission is to accelerate UHC through implementing multi-faceted sector-wide approaches. The organization carries out its mandate through exploring ways that are sustainable, transparent and good-for-people (fit-for-purpose). They also find alternatives to public funding of UHC, overseas development assistance, individual donors, foundations and corporate social responsibility (CSR). 

RaHa Solutions’ main goal is to build a global network of people that create new ways to finance UHC. In Kenya, RaHa Solutions has set footprints in three counties namely Kakamega, Kitui and Vihiga. Thus, it’s a welcome move to accelerate UHC achievement in Kenya through sustainability, transparency and to fund UHC acceleration using alternatives to tax-based funds, overseas development assistance ventures, individual donors, foundations and cooperate social responsibility (CSR).

RaHa Solution interventions, accelerateUHC, and linkages towards accelerating UHC attainment

RaHa Solutions has a specific portfolio aimed at fostering and promoting good health among vulnerable population. Currently, the programmes are implemented as a single intervention or in partnership with government related agencies, with the aim of accelerating attainment UHC at community level. The solutions are tailored towards addressing various SDGs facets which includes innovative WASH activities; and minimising gender disparity in education among children which remains a critical subject to be overlooked in poor rural areas where poverty is the order of the day. The RaHa interventions composes of 4 distinct but interwoven interventions and they are summarized as follow: 

a)   Provision of Free Medical Services; Households within a certain community that are excluded from access to health care services are nominated for UHC by community health  workers (CHWs) and nurses who are specifically engaged for the intervention. Once nominated, the households receive free medical services. 

b)  Menstrual hygiene care: In regards to menstrual hygiene through the RaHa Solution UHC package, girls are issued with reusable sanitary towels that are antimicrobial (intelligent towels) with a 4-years use period. CHWs are also given a token whenever they give health talks on menstrual health management and distribution of reusable sanitary towels.

c)    Rain water harvesting and provision of toilets: Lastly, the intervention provides the water starved communities with tanks to harvest rain water. Alongside the above benefits, other interventions  includes provision of clean water to villages and schools by sinking boreholes in a convenient location with enough water volume to serve a community with a guarantee of 3- year water source capacity guarantee per borehole. 

Proposed 3-in-1 RaHa intervention package and linkages towards accelerating UHC attainment

RaHa Solutions aims at contributing towards attainment of UHC through progressive increase of communities with essential health services through health financing by giving free medical services to households; giving rainwater harvesting systems to villages (that contain the households) and to schools (in the villages); protecting rainwater from pollution by giving toilets to the villages and schools; increasing doctors’ virtual presence in the villages and schools (as doctors’ physical presence in villages is very low); and, giving reusable sanitary towels to girls that are in the households (this also helps girls to complete schooling).

This 3-in-1intervention package is an innovation which has not been rolled before in low-middle income countries. It is anticipated that as opposed to traditional, silo models of care which are failing to deliver effective and better health programs outcomes, this new model will deliver more benefits to the community and thus accelerate attainment of UHC in Kenya. 

The Research Problem

The current UHC national policy and framework is suggestive of a uniform approach for counties roll-out and scaling-up in the 4 pilot counties that served as model sites. Most interventions were stand-alone / single interventions models of healthcare service delivery.   In addition, there exist fragmented health delivery care models which also lack a well-developed, people-centered execution plan. Furthermore, there is also evidence of low level of inter-sectoral collaboration (i.e. water, education, public works sectors) at the community level to affect health promotion. Whereas, there are no shortage of innovations and interventions  of health models in the country, the challenge is that a large proportion of them have failed to consider whether demand or political good will for their uptake within the public sector (communities) exists. Perhaps most significantly, the processes by which many innovations are designed and tested typically excluded or relegated government participation until the very final stages. Thus, this implementation research aims at exploring anticipated accessibility and acceptability of RaHa Solutions 3-in-1 multi-faceted intervention package towards acceleration of UHC attainment in Kitui County.

Justification for the Study

It is imperative that new healthcare delivery models is piloted before making a business case for their scale-up. Implementation research seeks to provide evidence and insights on what works within real world conditions, rather than trying to control these conditions or to remove their influence as causal effects (Peter et al., 2013). This implies working with populations that will be affected by the intervention, rather than selecting beneficiaries who may not represent the target populations of an intervention. In addition, context plays a central role in implementation research. Context can include the social, cultural, economic, political, legal and physical environment, as well as the institutional settings, comprising various stakeholders and their interactions, the demographic and epidemiological conditions (Protor et al., 2010). There is therefore need to carry out a feasibility study to inform access and acceptability of accelerateUHC interventions program with a view to scale up its uptake. The implementation outcome variables describe the international actions to deliver services. The implementation outcome variables include acceptability, adoption, appropriateness, feasibility, fidelity, implementation costs, coverage, and sustainability which in ideal scenario serve as indicators of successful implementation of intended programs, projects or interventions (Peter et al., 2013). 

Research Questions

(1)  How accessible and acceptable is the proposed free medical services among selected communities in Kitui County?

(2)   How accessible and acceptable are the WASH practices among selected communities in Kitui County?

(3)  What are the community perceptions on RaHa Solution 3-in-1intervention package in Kitui County?

General Objective 

Assessment of anticipated accessibility and acceptability of accelerateUHC, RaHa Solutions’ 3-in-1 intervention package towards acceleration of UHC attainment.

Specific Objectives

1. To determine anticipated accessibility and acceptability of the proposed free medical services, 
2. To determine anticipated accessibility and acceptability of integrated WASH interventions among the communities,
3. To explore community perceptions of the anticipated RaHa Solutions 3-in-1 intervention package.

MATERIALS & METHODS

Study Design

A convergent parallel mixed methods descriptive study design (Ozawa & Pongpirul, 2014) will be applied. This study design entails combining quantitative and qualitative methods in parallel at data collection and analysis. The aim is to provide a general understanding of the implementation problem in detail. Convergence of quantitative and qualitative findings will be at the analytical – interpretation stage of the study.

Study Area

Kitui County is in the former Eastern Province of Kenya. Its administrative capital and largest town is Kitui, although Mwingi is also another major urban center. The county has a population of 1,136,187 (KNBS, 2019 census) and an area of 30,430 km squared. It lies between latitudes 0°10 South and 3°0 South and longitudes 37°50 East and 39°0 East. It shares its borders with seven counties; Tharaka-Nithi and Meru to the north, Embu to the northwest, Machakos and Makueni to the west, Tana River to the east and southeast, and Taita-Taveta to the south. 

Map of Kitui County showing various sub-counties

Source: (1) (PDF) Socio – Economic Benefits and the Associated Environmental Degradation Effects of Osyris lanceolata (Hochst & Steudel) Utilization in Kitui County, Kenya (researchgate.net)

Kitui County was selected purposefully by the research team out of the two other counties, that is Kakamega and Vihiga, where RaHa Solutions has been implementing single module public health interventions. The geographical profile of the county has 2 important features namely arid-and-semi arid lands (ASAL) as well as agricultural highland which are important conditions for this implementation research. In addition, the southern part of the county has an important road network which sustains a number of livelihoods along the Northern Road Corridor. Thus, Kitui County hypothetically can be divided into poverty regions (northern region) and economic zones (central and southern regions). 

Target Population

The study will target different population groups living in Kitui County based on the research specific objectives as profiled in Table 1.

Table 1: Description of the various targeted population by objective and study collection methodology

Objectives	Target Population	Methodology	Expected Outputs
1.  To determine anticipated accessibility and acceptability of the proposed free medical services	Household heads	Quantitative (questionnaire)	Level of anticipated accessibility and acceptability of free medical services
2.  To assess the anticipated accessibility and acceptability of the proposed free medical services.	CHVs	Qualitative (IDIs) – 10 interviews	Level of anticipated accessibility and acceptability of free medical services.   Capacity of CHVs to use phones for tele-consulting
3.  To determine anticipated accessibility and acceptability of the integrated WASH interventions among the communities.	Household heads	Quantitative (questionnaire)	Level of anticipated accessibility and acceptability of WASH among the communities.
4.  To explore community perceptions on accelerateUHC, RaHa Solutions’ 3-in-1 intervention package.	Ø Opinion leaders Ø Local administration Ø Health care providers Ø MoE/School heads Ø CHVs Ø Community groups {Youth (18-24 years); women; men; older persons; PLWA}	Qualitative (FGDs and IDIs)	Information on community perceptions on accelerateUHC, RaHa Solutions’ 3-in-1 intervention package.

Inclusion and Exclusion Criteria 

i). Inclusion criteria 

·      Adults 18 years and above, 

·      Resident of the area who have lived in the study area for at least 1 year,

·      Those who give written consent to participate. 

ii). Exclusion criteria 

·      Persons deemed to have a conflict of interest,

·      Household decision makers and community participants who decline to participate. 

Sample size determination 

A common measure of precision for estimating an indicator is its relative standard error (RSE), which is defined as its standard error (SE) divided by the estimated value of the indicator. The standard error of an estimator is the representative error due to sampling. The relative standard error describes the amount of sampling error relative to the indicator level and is independent of the scale of the indicator to be estimated. 

To estimate a proportion π, we calculate the RSE as:

Inclusion and Exclusion Criteria 

i). Inclusion criteria 

·      Adults 18 years and above, 

·      Resident of the area who have lived in the study area for at least 1 year,

·      Those who give written consent to participate. 

ii). Exclusion criteria 

·      Persons deemed to have a conflict of interest,

·      Household decision makers and community participants who decline to participate. 

Sample size determination 

A common measure of precision for estimating an indicator is its relative standard error (RSE), which is defined as its standard error (SE) divided by the estimated value of the indicator. The standard error of an estimator is the representative error due to sampling. The relative standard error describes the amount of sampling error relative to the indicator level and is independent of the scale of the indicator to be estimated. 

To estimate a proportion π, we calculate the RSE as:

RSE=SQRT((1-f)/n×N/(N-1)×π(1-π)/π))/π

Where N is the population size in the survey domain, n is the sample size, f is the sampling fraction n/N, and π is the proportion we wish to estimate.  

Solving for the sample size n we get:

When the population size N is large relative to the sample size n,  the calculation above simplifies to:

n= 1/(RSE x RSE) x 1-π)/π

The RSE depends on the unknown proportion π, so it is customary to set π = 0.5 to carry out the calculations. Setting RSE to be 7%, and solving the equation above for n gives a sample size of 205.  

Adjusting the sample size for design effect (DEFF) and non-response

Adjusting sample size by a design effect (DEFF) factor of 2 (due to clustering) and a non-response rate of 20% gives 513 respondents. For this study 600 respondents will be considered (200 per Sub-county).

Sampling procedure

Multi-stage cluster sampling procedure will be used as described in the subsequent sections. .

Ø  Sub-county selection: Kitui County is divided into 3 zones (North, Central and South) and in each zone, one Sub-county will be selected using simple random sampling method.

Ø  Community Health Units (CHUs) selection: In each Sub-county, a listing of CHUs will be obtained. Applying a uniform sample take of 20 participants per CHU, 10 CHUs per Sub-county are needed and selection will be done using systematic sampling with a random start. 

Ø  Participants’ selection: In each selected CHU, Community Health Volunteers (CHVs) will assist in developing a household sampling frame. The household sampling frame will be used to select the required number of households per CHU by applying systematic sampling with a random start. In the selected households respondents will be household heads.

Data Management and Analysis Plan

Quantitative Component 

For the quantitative part of the study, a questionnaire will be employed. It is envisioned that this part of the study will strengthen research by quantifying findings providing proportions on anticipated accessibility and acceptability of the proposed package. Quantitative data capture will be captured using tablets by research assistants (RAs) that will be recruited and trained on data collection using Open Data Kit (ODK). At the end of each data collection day, all finalized records in the tablets will be uploaded to a secure server.

Data will be downloaded from the server into an excel file and after validation, exported to SPSS. Data analysis will be performed using SPSS (ver. 22.0). Exploratory data analysis (EDA) will be employed at the initial stage of analysis to uncover the structure of data and identify outliers or unusual entered values. Descriptive statistics such as proportions and frequency distributions will be used to summarise categorical variables while measures of central tendency such as mean, standard deviations, median, and interquartile range (IQR) will be used to summarise continuous variables.

Qualitative Component

Focus Group Discussions will be conducted among the general population groups including:  women of reproductive age, youth, and elderly persons drawn from the community health units and CHVs in the sub counties selected. The CHVs will be approached to identify the communities. Additionally, in-depth interviews (IDIs) and key informant interviews (KII) will also be conducted among opinion leaders, CHWs, local administration, and Ministry of Education (MoE) /school heads within the selected study counties. This exercise will be conducted in appropriate conducive venues moderated by social scientists with qualitative data collection expertise backed up by note takers. Language barriers will be addressed appropriately. Qualitative data will be collected at source using FGDs, IDI and KII guides. These guides will be used to address issues such as availability of water resources, adaptation of telemedicine and eHealth, the health needs of the community at large, barriers and facilitators of health seeking, commonly adapted community insurance initiatives, and perception of the communities on intervention of new water and hygiene technologies. Fifteen (15) FGDs and 21 IDS/ KIIs will be conducted in 3 sampled sub counties. FGDs will be conducted either at a school, church or health facility. FGD’s and KII will take approximately 45 minutes. FGD participants will be facilitated with transport. KII will be done at the participants’ offices.

After recordings, data will be transmitted directly to the server and translations will start immediately. The data collectors will be facilitated with internet so that transmission of data is done in real time to minimize the risk of loss. The recorded data will be transcribed verbatim and translated into English. Familiarization of the data will be carried out and any questions arising from transcription and translation addressed. Data will then be organized and analyzed thematically (into themes and sub themes developed to respond to each specific study objectives).  Findings will be presented in narrative form and supported by verbatim quotes identifying convergent zones with the quantitative data.

Ethical Consideration

Ethical approval to conduct the study were sought from, and granted by, KEMRI Scientific Ethics Review Unit (SERU) and the National Council for Science, Technology, and Innovation (NACOSTI). The intention to conduct the research will be presented to the relevant administration and the concerned authorities of the National and County Government. The researcher will present an official written document to the authorities seeking approval. Information about the study will be explained to the local administration and community. Selected region authorities will be contacted before the study commences to ensure timely planning and study processes. Privacy and confidentiality will be adhered to throughout the study where serial numbers, rather than study participants’ names will be assigned to each study participant. Data collected from the study will be strictly handled and used by the study team and for the study purpose only. The integrity, dignity, and privacy of the study participants will be maintained at all-time throughout the study. All data collected, including the laboratory analysis results, will be kept confidential and will only be accessible to the research staff. 

Informed consent will be sought from all eligible participants. The participants will be informed about their rights to agree or refuse to participate in the study and that they can stop participation at any time without any consequences. They will also be informed that refusal to participate will not interfere with any privileges they may have in the health facilities, community, or schools. The risks and benefits of the study will be clearly stated to the study participants.

Knowledge Management & Knowledge Translation 

Ø  Expected Application of the Research Findings: The findings of this survey will be instrumental in continuing the adaptive learning of what works as well as informing RaHa Solutions’ scale-up program to other counties in Kenya. Scaling-up promising innovations and interventions require prior evidence so as to inform programming aspects in order to make it adaptive intervention and align with changing health systems structures and processes.

Ø  Dissemination Plans: The research team anticipate to hold dissemination meetings with Kitui county health and water service providers with a view to share findings of this survey. Generating the evidence and convening key stakeholders for review and discussion is vital to the broader demonstration of impact, which in turn helps to establish and sustain credibility, ownership, demand, resourcing and political backing which are necessary to accelerating UHC in Kenya. Targeted message in form of research-to-policy-briefs as well as infographics with a view to encourage evidence informed decision making relating to multi-sectoral partnerships towards accelerating UHC in Kitui County. Manuscripts will be developed and published in peer reviewed journals. 

Work Plan / Duration of the Project

Early findings of this implementation research activities is planned to be released within 6 months after commencement now that  approvals and the granting of research permits has happened. Dissemination to donor, community members as well as to other decision makers will follow thereafter.  

Budget

	Item Description	Unit	Quantity	Duration	Rate	Total
1	Proposal Development	persons	15	4 meetings	3,500	210,000
2	Ethical approvals SERU /NACOSTI/ County	No.	1	1	130,000	130,000
3	Sensitization and Mobilization  and RAs recruitment (Facilitation allowance)	No.	1	1	200,000	200,000
4	Pre-testing of the study tools	Persons	15	1	2500	37500
5	Logistics and DSA (facilitators and Drivers)	No	4	6	10,500	218,400
6	Fuel for logistics	No	1	6	5000	30,000
7	Training of Research assistants (Facilitation allowances)	No	15	3	2500	112,500
8	Facilitators DSA	No.	5	5	10,500	262,500
9	Airtime RAs	No	15	1	500	7,500
10	Bundles for transmission of data	No.	15	1	500	7,500
11	conference package	Persons	20	3	3500	210,000
12	Pre-testing of the study tools	Persons	15	1	2500	37500
13	Car Hire	No.	1	1	20000	20000
14	Data collection (Audio recorders)	No	5	1	10,000	50,000
15	Data collection (Tablets)	No	20	1	18,000	360,000
16	Data Hard Drive	No.	1	1	7,000	7,000
17	Qualitative Data collection Participants Reimbursement	Persons	150	1	500	75,000
18	KII mobilizers	Persons	15	1	1000	15,000
19	Communication	No.	15	25 days	500	187,500
20	Transport (Fuel)	No.	4 vehicles	12	5,000	240,000
21	Vehicle maintenance	No.	4	1	20,000	80,000
22	Personnel cost (DSA,)	No	10	13	10,500	1,365,000
23	Drivers (DSA)	No	4	13	4,900	254,800
24	Effort compensation (6months)					2,976,846
25	Data Analysis quantitative					200,000
26	Data Analysis qualitative					200,000
27	Transcribers	No.	4	7	2,000	56,000
28	Report Writing Workshop (DSA, Conference package, and fuel)	Workshop				1,308,900
	Post Evaluation survey	persons	15	25 days		2,000,000
29	Dissemination (publication and conference)					500,000
30	Stationery					100,0000
31	Translation of study tools (Kiswahili & local language)					100,000
	Total					11,544,446
32	KEMRI Administrative costs (10% of the total cost)					1,154,444
	Grant Total				Total	12,698,890

Budget Justification 

a)     Proposal development: To meet cost of study team meeting for proposal development and coordination of the study. The rates are estimated for 4 meetings of the project period.  

b)    Ethical approvals: It includes SERU, NACOSTI and County approvals.

c)     Field Personnel costs: These are costs towards data collection for Sensitization and Mobilization and RAs recruitment (Facilitation allowance), logistics and DSA (facilitators and Drivers), fuel for logistics, training of Research assistants (Facilitation allowances), facilitators DSA, Airtime RAs, bundles for transmission of data and conference package

d)    Training costs: All field teams will need training to orient with the field activities in line with the tools. These will include tool pretests and piloting costs Trainings will be undertaken at a central training venue for standardization of the methods 

e)     FGD Costs: FGD costs include venue hire for FGDs sessions and reimbursement of transport costs to the participants. 

f)     Equipment: The data will be collected using electronic data capture systems, the equipment costs will go towards purchase of data capture tools, hard drives for data backup.

g)    Communication costs: To facilitate communication between teams. 

h)    Stationary: For purchased of field and office stationary including printing paper, Manila paper, notebooks, training materials, field bags etc. 

i)      Transcription and translation: To meet costs of all audio collected data for transcription and translations. Costs will be based on hours per recording  

j)      Data Analysis and reporting: to meet costs of data cleaning of both qualitative and quantitative data sets, creating of themes of the qualitative data The costs also include report writing meetings and workshops by the research team.

k)    Dissemination costs: Include publication fee and conference packages. 

Role of Investigators

Investigator	Specialization	Role
Dr. Prisca Otambo	Social Scientist	Coordination of the study. Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs.
Dr. Joseph Mutai	Social Scientist	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs.
Dr. Judy Mwai	Environmental Health	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs.
Mr. James Kariuki	Health Systems research	Proposal development, data collection, data management, report writing and dissemination. Will also be involved in developing questionnaire and ODK kit.
Mr. Erastus Muniu	Biostatistics	Proposal development, methodology and analyze quantitative data.
Mr. Ismail Ahmed	Public Health Researcher	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting Quantitative data.
Mr. Philip Ndemwa	Food Scientist & Nutritionist	Participate in proposal development, data collection, data management; report writing and dissemination.
Mr. David Mathu	Social Scientist	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs.
Ms Sarah Karanja	Social Scientist	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs.
Rodgers Ocheing	Human Nutrition	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs
Lucy Magige	Human Nutrition	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs
Steve Onteri	Human Nutrition	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs
Ms. Lucy Magige	Human Nutrition	Participate in proposal development, data collection, data management; report writing and dissemination. Will also be involved in conducting FGDs and IDIs
Dr Zipporah Bukania	Human Nutrition	Administrative support for the project, data collection, data management, report writing and dissemination.
Mr. Titi Kadu	Director & Coordinator, RaHa Solutions	Administrative and funding support for the project.

References

Abu, T. Z., Bisung, E., & Elliott, S. J. (2019). What If Your Husband Doesn’t Feel the Pressure? An Exploration of Women’s Involvement in WASH Decision Making in Nyanchwa, Kenya. International Journal of Environmental Research and Public Health, 16(10), 1763. https://doi.org/10.3390/ijerph16101763.

Chapman, A. R. (2016). Assessing the universal health coverage target in the Sustainable Development Goals from a human rights perspective. BMC International Health and Human Rights, 16(1). https://doi.org/10.1186/s12914-016-0106-y

Kenya National Bureau of Statistics (2020). National Population and Housing Census 2019, Nairobi, Kenya. Accessed on May 2022. Https://www.knbs.go.ke 

Ozawa, S., & Pongpirul, K. (2014). 10 best resources on mixed methods research in health systems. Health policy and planning, 29(3), 323-327.

UN General Assembly. (2015). Transforming our world: The 2030 Agenda for Sustainable Development. https://www.refworld.org/docid/57b6e3e44.html

UNICEF & WHO. (2017). Progress on drinking water, sanitation and hygiene: 2017 update and SDG baselines, Joint Monitoring Programme.

WHO, 2020, Novel coronavirus (2019-nCoV) situation report. World Health Organization, 2020 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200205.

Boschi-Pinto, C. V. L. (2008). Estimating child mortality due to diarrhoea in developing countries. Bull World Health Organ 86 (9), 710-717.

Sire, J.M., Garin, B., Chartier, L., Fall, N.K., Tall, A., Seck, A. (2013). Community-acquired infectious diarrhoea in children under 5 years of age in Dakar, Senegal. Paediatric International Child Health, 33 (3), 139–144.

Siziya, S., Muula, A.S., Rudatsikira, E. (2013). Correlates of diarrhoea among children below the age of 5 years in Sudan. Africa Health Sciences, 13 (2), 376–383.

World Health Organization (WHO). (2017). No TiUHC 2030 International Health Partnership Core Team Report tle.

Gera, R., Narwal, R., Jain, M., Taneja, G., & Gupta, S. (2018). Sustainable development goals: Leveraging the global agenda for driving health policy reforms and achieving universal health coverage in India. Indian Journal of Community Medicine, 43(4), 255–259. https://doi.org/10.4103/ijcm.IJCM_41_18

World Health Organization (WHO), Raising revenues for health in support of UHC: strategic issues for policy makers: Health financing policy brief No. 15.1, November 2015)

Boschi-Pinto, C. V. L. (2008). Estimating child mortality due to diarrhoea in developing countries. Bull World Health Organ 86 (9), 710-717.

Okech, T. C., & Lelegwe, S. L. (2015). Analysis of Universal Health Coverage and Equity on Health Care in Kenya. Global Journal of Health Science, 8(7), 218–227. https://doi.org/10.5539/gjhs.v8n7p218 

World Health Organization (2014). What is universal health coverage? Geneva: World Health Organization; 2014. Available from: http://www.who.int/features/qa/universal_health_coverage/en/

Ranabhat CL, Atkinson J, Park M-B, Kim C-B, Jakovljevic M.(2018). The influence of universal health coverage on life expectancy at birth (LEAB) and healthy life expectancy (HALE): a multi-country cross-sectional study. Front Pharmacol. 2018. September 18;9:960.10.3389/fphar.2018.00960  

World Bank and World Health Organization (2017).  Tracking universal health coverage: 2017 global monitoring report. Geneva and Washington, DC: World Health Organization and International Bank for Reconstruction Bank and Development / The World Bank; 2017. Available from: http://apps.who.int/iris/bitstream/handle/10665/259817/9789241513555-eng.pdf;jsessionid=F7629934694ED5F3EF91705B3F420237].

Tangcharoensathien V, Mills A, Palu T (2015). Accelerating health equity: the key role of universal health coverage in the sustainable development goals. BMC Med. 2015. April 29;13(1):101. 10.1186/s12916-015-0342-3

Ghebreyesus, Tedros A. (2019). “Healthcare for All: Every Country Can Do It—An Essay by Tedros Adhanom Ghebreyesus” BMJ 367: l6790. https://doi.org/10.1136/bmj.l6790.

Kruk, Margaret E., Anna D. Gage, Catherine Arsenault, Keely Jordan, Hannah H. Leslie, Sanam Roder-DeWan, Olusoji Adeyi et al. (2018). “High-Quality Health Systems in the Sustainable Development Goals Era: Time for a Revolution.” The Lancet Global Health 6 (11): E1196–252. https://doi.org/10.1016/S2214-109X(18)30386-3.

McClellan, Mark, Lucas Scherdel, Andrea Thoumi, and Krishna Udayakumar. 2020. “Achieving Universal Health Coverage through Value-Based Care and Public-Private Collaboration.” Brookings. Last modified September 20, 2019. https://www.brookings.edu /blog/future-development/2019/09/20/ achieving-universal-health-coverage-through-value-based-care-and-public-private-collaboration.

OECD. (2016). “Universal Health Coverage and Health Outcomes: Final Report.” Last modified July 22, 2016. https://www.oecd.org/health/health-systems/Universal-Health-overage-and-Health-Outcomes-OECD-G7-Health-Ministerial-2016.pdf.

Peters DH, Adam T, Alonge O, et al. (2013). “Implementation Research: what it is and how to do it”. Br J Sports Med 2014;48:731–736. Accepted 08 October 2013 Br J Sports Med 2014;48:731–736. doi:10.1136/bmj.f6753

Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. (2010). “ Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda”. Adm Policy Ment Health 2010;38:65–76