Culture, barriers, and enablers of primary health care quality improvement in Kenya

Odhus, Camlus and Limmer, Mark and Harding, Andrew (2025) Culture, barriers, and enablers of primary health care quality improvement in Kenya. PhD thesis, Lancaster University.

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Abstract

Introduction Improving the quality of primary health care (PHC) is an urgent priority, given millions of deaths attributable to poor quality health services. Yet, little is known about the culture of teams involved in PHC Quality Improvement (QI) in Kenya, and the related barriers and enablers. Aim To describe the culture of teams involved in PHC QI and explain how PHC QI is enabled or constrained in the Kenyan context. Methods First, an integrative review of the literature synthesised evidence on the culture, barriers to and enablers of PHC QI in low- and middle-income countries (LMIC). Secondly, a focused ethnographic study, inspired by critical realism (CR), made use of participant observation, qualitative interviews, and document reviews. The data were analysed thematically to explore the culture of PHC QI. Framework analysis helped describe barriers to and enablers while retroductive reasoning provided viable explanations linking observed constraints and wider social structures. Findings Most of the findings from the integrative review came from sub-Saharan Africa. The themes related to the microsystem and individual health worker levels, those intrinsic to the QI intervention, the organisation and team implementing QI, the larger health system, external environment including wider social structures, and the execution of QI intervention. The review found many similarities and few contrasts across varied country contexts. Importantly, barriers and enablers are closely related and dialectical, likely affecting and affected by each other. Building on the review, this research explores three themes of culture of PHC QI (manifestations of knowledge and practices, underlying values and attitudes, and overarching structures) in three categories, namely micro-culture, sub-group culture, and organisation-wide culture patterns. The research also describes the barriers and enablers of PHC QI, innovatively drawing from the consolidated framework for implementation research (CFIR) and the model for understanding success in quality (MUSIQ). Through retroduction, the research points to poor governance in Kenya’s complex devolved health system as a major hindrance to building a culture-of-quality and the main underlying barrier for PHC QI. Conclusion The study found no institutionalised culture buttressing PHC QI, with many barriers. This study extends knowledge of PHC QI culture by developing two novel, adaptable and transferable models for future research. The study makes viable recommendations to transform PHC quality, given existing constraints.