Policy vs Practice: Two modes that reflect decision-making in the Kenyan health system
This is a fifth story in a blog series sharing insights from a Human-Centered Design research study of the immunization program in Kenya in early 2020. Please read the previous stories for more context on the work, our approach, as well as other insights from this research. A full report of the initial findings is also available for download.
Christopher is a County EPI Manager in eastern Kenya. Over the past 20 years, he has worked his way up through the system, starting out as a nurse, a hospital employee, eventually ending up in his current role. He oversees all immunization activities, including making sure vaccines are properly stored and available at all the facilities to meet demand. His main goal is to ensure the country’s immunization program runs smoothly.
While his background has given him a good understanding of the system and region he is working in, making it easier to navigate the hurdles of the job, he still faces many challenges. Despite limited resources, he manages to organize the target setting meetings necessary to plan and anticipate the County’s needs accurately. However, no matter how diligent his team is about reviewing last year’s data and considering all other factors that may determine performance, he still feels he is not set up for success.
For one, he knows the targets passed on to him from the National level are based on population numbers that don’t match the information his Facilities are collecting on the ground. This means any estimates he makes about the amount of vaccines his County will need are inaccurate from the start.
Equally problematic is the fact that his vaccine orders are almost never delivered on time or in full. Regional vaccine stocks rarely fully meet demand as per the schedule, meaning depot managers send what they can, when they can, to minimize the risk of stockouts across the region. This unpredictable supply from the top means Christopher is constantly re-shuffling resources and making last minute arrangements for transport to the Sub Counties and Facilities.
As a result, much of his meticulous planning work feels in vain. In the end, strategic, data-driven decision-making makes way for last minute judgement calls which rely almost exclusively on personal experience and understanding of the context.
We recently spoke to Christopher as part of a joint effort between Sonder Collective, John Snow Inc. (JSI), and the Ministry of Health in Kenya, to understand challenges around collecting and using data for decision-making in delivering immunization services. As part of our conversations, it became apparent that managers like Christopher often fluctuate between conducting time-consuming, often unrealistic, planning activities and making on-the-spot judgment calls in response to urgent needs. We consider these two behavior types as distinct decision-making modes that help us understand how actual decisions are made within the immunization program in Kenya.
Policy: Formal, data-driven planning processes which rarely reflect the reality on the ground
Much effort was dedicated towards official, formulaic, data-based planning procedures such as annual target setting or generating workplans aimed at deciding on the use of resources and policies for the immunization program. While such activities were very strategic and relied heavily on data, they often failed to reflect the reality on the ground. The data used was widely seen as inaccurate, making targets and projections unrealistic. To compound this, the funds and resources that the planning depended on hardly materialized on time or in full.
Practice: Quick judgement calls grounded in local context, but rarely based on available data
Because many of the formal planning exercises were not sufficiently grounded in the reality on the ground, the primary way in which decisions were actually made was through a reactive response to a problem at hand, such as dealing with shortages, stockouts, or issues at the facility. Such “putting a fire out” decisions were often made very quickly and relied mostly on personal experience, rather than any formal data sets or rigid bureaucratic standards.
Policies and procedures are necessary to establish standards and expectations across a large health system that involves many, many people. However, we also have to recognize that the practice and reality can dictate differently, and policies may need to be adjusted to meet new expectations.
Healthcare workers create workarounds that are more responsive and agile to address these policy short-falls, such as inaccurate target populations and static annual workplans. These workarounds still respect standard policies while adapting to fit the specific context.
Let’s use this energy to support and recognize the decisions with real impact — the responsive decision-making that may depend more on intuition and agility than on the protocols/policies informed by inaccurate data.
This story was co-written by Emilia Klimiuk, Wendy Prosser, and Chloé Roubert.
From more insights from this study, stay tuned for additional stories in this blog series. You can also download our initial Kenya findings report for more information.
