# 1. Introduction

Health is an essential component of human capital formation, especially in the early years of the lifecycle.<sup>2</sup> Inadequate infrastructure affects both demand for health care services as well as supply. On the demand side, many people in low- and middle-income countries face barriers that prevent or limit their access to the health care services they need. Excessive travel times to reach facilities, lack of information, and limited health care resources impact remote and vulnerable populations the most. On the supply side, inadequate infrastructure hampers the functioning of health care facilities and the quality of their services. These barriers not only affect access to health services but also the quality of services people receive. Therefore, policies to improve access to health services should also focus on improving the quality of provided services.<sup>3</sup> While many dimensions that affect the quality of health service delivery have been documented in the literature, access to infrastructure remains understudied, especially on the supply side. Investments to improve access to infrastructure such as roads, electricity, and information and communications technology (ICT) hold the potential to enhance the quality of health service provision. This is particularly true in low- and middle-income countries, where access to quality infrastructure remains a challenge in rural and hard-toreach areas. Not only do more and better roads facilitate the access of patients to health facilities, but they may also allow facilities to attract more staff and ease the supply of key inputs such as medicines and vaccines. Likewise, lack of reliable electricity may compromise health care provision as electricity enables lifesaving interventions, the maintenance and use of essential equipment, and the ability of health facilities to operate for extended hours, particularly at night. Similarly, access to the internet allows facilities to have better information, reach more patients, and better manage their supply chains. This paper aims to contribute to the literature by exploring the extent to which more and better infrastructure might improve the quality of health services provision in low- and middle-income countries by studying the Kenyan context.

Kenya has made great progress in increasing the availability of health care services in the last decade, but much remains to be done (WHO, 2017). A child born today in Kenya is likely to only achieve 55% of her/his potential according to the latest update of the Human Capital Index (World Bank, 2020), which includes measures of child and adult survival rates, stunting and access to and quality of schooling. While Kenyan county governments have prioritized investments in the health sector, especially in the construction of new health facilities and purchase of medical equipment and ambulances, not many efforts have been made to ensure that health facilities have access to reliable infrastructure (Mugo, et al., 2018).<sup>4</sup> According to the latest 2018 Service Delivery Indicators (SDI) report, only 56% of primary-level health care facilities have access to stable electricity and only 15% of health facilities use ICT for supply chain management.

Improving the access and quality of infrastructure remains a challenge in Kenya. Despite an increase in access to energy by 50 percentage points over the past ten years, which has translated into 70% nationwide coverage, 30% of the population still has limited access to reliable electricity (World Bank, 2021). The latest Rural Access Index in Kenya shows that 56.8% or about 13.4 million rural residents are still unconnected to

> 2 See Bleakley, 2010; Case, Fertig, & Paxson, 2005; Conti, Heckman, & Urzua, 2010; Knudsen, Heckman, Cameron, & Shonkoff, 2006.

> 3 Within Millennium Development Goals (MDGs), from 2000 to 2015, there was an increase in health coverage in low- and middle-income countries (LMICs). But health outcomes did not improve at the same rate for every country or everyone within each country. Despite the increase in the coverage achieved, low quality of services persists in many LMICs and high maternal and child mortality rates continue to be of serious concern. In this context, quality health services are essential to better human capital and healthier economies (WHO, 2018). There are many well-documented factors that affect the quality of health service delivery (Di Giorgio, et al., 2020; Gatti R. , et al., 2021; Mosadeghrad, 2014). For instance, providers’ effort and knowledge in primary care vary according to institutional settings (private or public, with their cost structure), and medical training -where the relationship is not strictly positive (Das, Holla, Mohpal, & Muralidharan, 2016; Das, et al., 2012).

> 4 The right to access quality health care is a basic human right guaranteed by the 2010 constitution of Kenya. In line with the law, the national government has made investments in interventions geared towards accelerating UHC for all Kenyans. In 2013, Kenya devolved health services to 47 semi-autonomous counties established in response to the new constitution of 2010, increasing local autonomy for managing health services (Achoki, et al., 2019).

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