# **II Setting and Context**

Primary healthcare in Kenya is delivered through tax-funded public (61%) and fee-charging private (39%) facilities.<sup>10</sup> Public facilities are managed independently by each of 47 counties following a process of devolution of responsibilities in 2010. Patients can choose what facility to visit. Prices in public facilities are administratively determined and substantially lower than prices in the private sector, which are set independently by each facility. Finally, facilities are divided by levels with Levels 2 and 3 providing primary care while Levels 4 and 5 also offer inpatient and advanced care (Figure S1, Supplemental Material shows examples of facilities at different levels of care).

Most health facilities operate in settings with some competition. In our study counties, 79% of all health facilities are in markets with 4 or more facilities (we define “market” more precisely in Section III) and 15% in markets with 2 to 3 facilities. The remaining 7% are “singleton” facilities, which tend to be publicly-owned and located in rural areas. A public sector option is available in 88% of markets catering to 98% of all patients, implying that even if all private sector facilities were closed, patients could still access healthcare. Mirroring the market structure, 70% of patients seek care in markets with 4 or more providers and 11% from singleton facilities. This distribution of markets in the study counties is similar to the rest of the country, although with more private facilities and greater competition (see Table S1 in Section 1 of the Supplemental Material).<sup>11</sup> Patient safety is regulated by the national government through nine “Boards and Councils,” each responsible for a different facet of healthcare delivery (for instance, the Kenya Medical Practitioners and Dentists Council licenses most health facilities, while the Kenya Medical Laboratory Technicians and Technologists Board addresses lab safety). Prior to the intervention, facilities were visited by inspection teams on an ad hoc basis based on the quota for the inspection period or by individual boards and councils, usually following a complaint or a serious adverse event. Four percent of facilities were inspected annually and the likelihood of two inspections in one year was zero.<sup>12</sup> Section 2 of the Supplemental Material provides details of the old inspection system.

Concerns around patient safety were raised after a national survey in 2012 reported that 2% of health facilities were compliant with minimum patient safety standards and systems. A subsequent study that used clinical observations thankfully suggested a more nuanced situation with variation across specific tasks. For instance, compliance was 87% with safe injections and blood draw practices but 2% for hand-hygiene. Even then, outpatients faced an average of 5.1 violations of infection, prevention and control (IPC) safety practices out of 7.5 observed indications where a safety action should have been taken (Bedoya et al., 2017). Despite these deficits, the quality of care in Kenyan

> 10Faith-Based and Non-Government Organizations account for 11% of facilities and 9% of patients in our baseline survey. These operate similarly to private facilities, except location decisions may be taken at a higher level.

> 11Differences between the data collected in the study counties and administrative data in other counties could also reflect under-counts of unlicensed providers in the latter (Table S1 in the Supplemental Material).

> 12Private communication with the Kenya Medical Practitioners and Dentists Council.

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