Implementation of Universal Health Coverage Program in Kisumu County, Kenya: Importance of Social Marketing Strategies

Universal Health Coverage is where communities have access to all needed health services without financial hardship. In Kenya, Universal Health Coverage (UHC) program was launched in December 2018, through a presidential decree. This study aimed to understand population needs, acceptability, and perceptions about UHC implementation. The study was undertaken in four pilot counties of Kisumu, Machakos, Nyeri and Isiolo between February and March 2019, using exploratory qualitative data collection techniques. However, this paper focuses on the County of Kisumu which was selected due to its high prevalence of infectious diseases. Respondents included women of reproductive age, men, youth, and elderly persons. In-depth interviews were conducted among health care providers and managers. Scientific and ethical approval was obtained from the Kenya Medical Research Institute’s Scientific and Ethical Review Unit (SERU). Consenting to participate was individualized. Analysis was done thematically. Findings suggest that UHC was understood variously by different groupings. Sensitization about the UHC programme was done through electronic media, by CHVs, education sessions, political class and outreaches. Planning for the programme was done by holding meetings, trainings for community registration and developing budgets. However there was a lot os misunderstanding, confussion and misconcepts about the UHC concept as it was seen as a means to seek for votes by politicians. Barriers for successful implementation included critically understaffed facilities. www.scholink.org/ojs/index.php/sshsr Social Science, Humanities and Sustainability Research Vol. 1, No. 2, 2020 23 Published by SCHOLINK INC.


Background
The right to health is one of the fundamental rights of every human being without distinction of race, religion, and political belief, economic or social condition. This message has since been repeatedly reinforced; perhaps most prominently in the 1978 Declaration of Alma-Ata (WHO, 2010). Since the turn of the century, the quest for Universal Health Coverage has gained momentum in numerous countries and in the global health community. In 2005, the member states of WHO endorsed UHC as a critical goal and stated that health systems must be further developed in order to guarantee access to necessary services while providing protection against financial risk. Accordingly, all UN Member States agreed to achieve UHC by 2030, as part of the SDGs. Many countries are already making progress towards UHC (WHO, 2007). Experiences have shown rising incomes, increasing total health expenditures and an expanding role for government in improving access to health care (William et al., 2011).

Social Maketing as an Important Tool in UHC Sell out
Social marketing is widely used to influence health behavior (Evans, 2006). Social marketers have often used this tool in a wide range of health communication strategies based on mass media; use of mediated (interpersonal) and marketing methods such as message placement promotion, dissemination, and community level outreach to sell a health program. Social marketing is therefore defined as the application of proven concepts and techniques drawn from the commercial sector to promote changes in diverse socially important behaviors such as drug use, smoking, sexual behavior. This marketing approach has an immense potential to affect major social problems if it is learned how to harness its power (Evan, 2006). By proven techniques, it means methods drawn from behavioral theory. Behavioral theorists believe that a better understanding of human behavior at work, such as motivation, conflict, expectations, and group dynamics, improve productivity. Persuasion psychology, and marketing science with regard to health behavior, human reactions to messages and message delivery, and the marketing mix or four Ps of marketing, i.e., place, price, product, and promotion, are the key principles in social marketing (Borden, 1964). These methods include using behavioral theory to influence behaviour that affects health; assessing factors that underlie the receptivity of audiences to messages, such as the credibility and likeability of the argument; and strategic marketing of messages that aim to change the behavior of target audiences using the four Ps (Petty, 1986). Importantly social marketers use a wide range of health communication strategies based on mass media; they also use mediated, for example, through a healthcare provider, interpersonal, and other modes of communication; and marketing methods such as message placement for example, in clinics, promotion, dissemination, and community level outreach. All these strategies are common in social marketing. But as communication channels for health information have changed greatly in recent years, a multimodal transactional model of communication www.scholink.org/ojs/index.php/sshsr Social Science, Humanities and Sustainability Research Vol. 1, No. 2, 2020 24 Published by SCHOLINK INC. (Backer, 1992) has been suggested as the most effective way to reach audiences about health issues (Hornik, 2002).
In India, during the swine flu H1N1 pandemic in 2009, a simple strategy of social marketing to prevent it by thorough hand-washing with liquid soap and water (added with commercial marketing of soap products) gained publicity with a high level of acceptance (Aras, 2009). Social marketing approaches therefore have been shown to have positive impacts for example smoking and alcohol-related problems, especially when they are carefully designed to engage specific groups (Perese, 2005). Needless to say that they gain a lasting effect when combined with a mix of additional educative, policy, legislative and intervention measures (Perese, 2005).
In Kenya, Universal Health Coverage (UHC) program was launched in December 2018 through a presidential decree, with an ambition to position Kenya as a leader in achieving quality and affordable healthcare in the African continent that would mark a key milestone and historic journey for the nation as it inched closer towards the realization of health for all.
This study sought to understand population needs, acceptability, perceptions and the extent of incorporating social marketing principals for the success of the UHC programme in Kisumu County.

Study Design
This was an exploratory qualitative study that collected data using in-depth interview techniques on population-driven needs for an effective UHC program; phenomenology and case studies approaches were used. Phenomenology involves describing situations as they appear, while experiences are an integral part of the study population. Exploration of causation (events, decisions, periods and policies) were discussed with a view to understanding the underlying principles. The main reason for choosing qualitative method is that derived data can help to develop an intervention (Bradley et al., 1999), it can also develop an understanding of how the intervention works and who it might be most effective for (MRC, 2000) and qualitative methods are important when it is intended to address vulnerable voices at community level as this study targeted also vulnerable populations.

Study Sites
The study was conducted in four UHC pilot counties of Isiolo, Kisumu, Machakos and Nyeri that the  GoK, 2008). Each County had unique findings and therefore these findings are from Kisumu County.
The findings from the other counties will be published in other papers.

Study Population
Data was collected from women of reproductive age (including pregnant women and caretakers of children under 5 years), men, youth, and elderly persons as consumers of healthcare services at the community level in Kisumu. In addition, information was also collected from healthcare personnel including County Health Management teams, facility-in-charges, hospital departmental heads, and healthcare service providers. The study also targeted other key stakeholders in the healthcare system including partners, policymakers and Politicians particularly Members of Health Ccommittee at County level.

Community Entry and Facility Selection
In the current devolved county government systems, the entry point into the community was facilitated through the County Executive Committee (CECs) of Health to inform about the study and seek County administrative approvals, as well as establish linkages with Community Health Strategy Focal Persons (CHFP) to support community mobilization, in consultation with the local leadership.
The selection of health facilities for the UHC study activities was done through a consultative process between the study team and the CHMT in Kisumu. Considerations for selected facilities included; representation of all facility levels, facility workloads (targeting high and low volumes) and facility accessibility by the community members among other considerations. Focus Group Discussion (FGDs) participants were randomly selected from community units of the selected facilities.  of the study objectives. Comparison across the collected data by source of information was made while collating similar and varied opinions of the themes relevant to the research objectives.

Ethical Clearance and Considerations
The study got approval and letter of support from the Ministry of Health, while scientific and ethical approval to conduct this study was obtained from the Kenya Medical Research Institute's Scientific and Ethical Review Unit (SERU) prior to study implementation. Written permission was also obtained from the County Director of Health. Consenting to participate either in the KIIs or FGDs was individualized.

Social Demographics
A total of 8 FGDs and 23 Key Informant Interviews were conducted in Kisumu County drawn from various categories of the study respondents. The minimum age of the participants was 27 years and the maximum age 59 years. In terms of gender distribution, 27 were females while 50 respondents were male.

Understanding of Universal Health Coverage
Universal health coverage means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. This definition of UHC embodies three related objectives: Equity in access to health services-everyone who needs services should get them, not only those who can pay for them; the quality of health services should be good enough to improve the health of those receiving services; and people should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.
Universal health coverage cuts across all of the health-related Sustainable Development Goals (SDGs) and brings hope of better health and protection for the world's poorest (WHO, 2019).
This study explored how communities and health workers understood UHC, the planning and sensitization process at county level which gave us an opportunity to interrogate the understanding of We also sought to understand sources of information on how UHC program was unveiled to the There were thoughts that the county government could subsidize the health care and if this was done, it could be an opportunity to make the programme a success.

Planning for UHC at County Level
We learned that at facility level some health workers were involved in the planning stage and this was critical because it ensured ownership of the programme. On why planning was important: "…the plans in place were to ensure that the system was ready for implementation. The second was to define the

package of services that would be provided to the population as part of UHC in Kenya. Number three was to get the resources to implement the defined set of services across the country" KII-CHMT
(Executive member, Health Management Team). Additional staff were quickly employed and trainings carried out to sensitize the community: "….some staffs were employed and there were trainings that were carried out to continue sensitizing those who were offering services." (KII-HW).
Departmental managers were involved in series of meetings and were also tasked to inform staff under them about the new initiative: "…, when the initiative was being brought on board we were called for series of meetings concerning the same. We were also tasked with sensitizing the health staff on the same and also sensitizing the community on the same", KII-CHMT In similar meetings budgets were discussed more so for the purchase of essential medicines and commodities as patients were projected to double. Laboratory in-charges were required to budget even for tests: "…the laboratory in-charges were

taken to do budgeting, in Naivasha somewhere in October. So each and every in-charge especially laboratory were supposed to go with the lists of the tests they do and do a budget estimation" (KII-HW).
At the same time the health management information system that was UHC friendly was developed. On equal strength bed coverage and work load were planned on how to manage the would be increasing patients. The electronic coding system was also managed so as to ensure billing records were kept even though bills were not paid. This was critical to understand the costing per patient: "… We have an electronic medical records system, prior to that we had our services that were coded with the prices, so when the UHC came now our clients were not supposed to pay. So we are just billing them but they are

Registration
Kisumu County signed a Memorandum of Understanding for technical assistance with Pharm Access Foundation to offer digital technology for healthcare. The partnership with Pharm Access was to ensure access to quality programs and loans for healthcare providers to strengthen the availability and quality of medical services in Kisumu. The county aimed to use the digital platform that included a mobile health wallet to help achieve Universal Health Care in a cost effective and transparent way. The mobile technology, was therefore to enable the county community health volunteers to enroll the population onto UHC. By harnessing the power of mobile technology, Kisumu was leading in the frontline of healthcare innovation. So Registration was a key event in the UHC implementation process. It included having an ID card and birth certificates. Youths and CHVS were recruited and trained to register community members for the program in order to speed up the exercise. "…there is need to do a more vigorous and thorough registration of the beneficiaries so that they can be identified at the delivery point" (KII, WHO Rep.).

Involvement of Community Health Volunteers (CHV) in UHC Implementation
The concept of community-based health volunteer system has gained its popularity in developing countries to overcome the increasing demand for health care services and the shortage of formal health care providers. It was evident that Community Health Volunteers (

…CHVs is a resource that needs to be tapped into, but again I think it is an area that we have to be careful in terms of the whole agenda of community health services",
(KII_Implementing Partner ).

Sensitization Process
Community Empowerment (CE) is the process by which relatively powerless people in the community work together to attain control over the events influencing their life (Joader, 2013 mothers' circles helped reduction of infant mortality; and many more (Laverack, 2011). Sensitization was adopted in this program as a strategy for UHC success. The study therefore sought to understand how it was done and by who and the medium used. It was noted that notice boards, health education sessions and outreaches were employed.
"…when the patient comes, to the facility, we start by health education before they seek care so our staff come as early as seven and give health education to our patients and the key areas that we need to educate them and we also have a community unit, a community unit linked to the facility composed of the community health workers that go to the community and educate them" KII-HW, "…preparations included capacity building of the health care workers, we are trying to boost our blood donations system so that we can monitor how much blood we have in the system, improve on our disease surveillance and reporting, specifically for disease surveillance and response where right now Kisumu is ranked second or third in terms of reporting of (DSR) in the country." (KII-HW)

Misconceptions about UHC Programme
It was noted that the community had misunderstanding of the UHC concept as they saw it as a means to seek for votes by politicians: "…when the people who were registering were walking around the

community the people were coming to ask us as CHVs if it's legit or it's a scheme to steal other people's votes." (CHV FGD).
The communities were not sure about the free health services that were being advertised about: "…there are some people in the community that are still afraid to be  There was also need to increase facility infrastructure to cater for storage concerns: "…One of the challenges am overseeing is the constant supply of commodities. There will be a time that there will

be shortage. As UHC is rolled out the number of patients increases and if the commodities are not there it can bring commotion between the staff and the community" KII-HW.
Sustainability of the programme was in question and it was an area that needed a lot of answers for the success

education it was very good, you know, schools, they went down. And we no longer hear about them.
All we hear about are private schools. We hope that will not happen to health", KII, CHMT.

Discussion
From the findings above it can be concluded that the UHC implementation programme was not well thought out and highlights the importance of application of social marketing strategies for the success of a new program. For example the community did not understand the concept of UHC. Some defined it as NHIF and others said it was a government health subsidy. While health workers were not given an opportunity to participate from a bottom-up point management perspective. They instead received orders to implement the program without adequate resources. The concept did not define the UHC package and enough time was not given for planning, training and sensitization.
Social marketing uses behavioral, persuasion, and exposure theories to target changes in health risk behavior. Social cognitive theory based on response consequences (of individual behavior), observational learning, and behavioral modelling is widely used (Railton, 2001). Persuasion theory indicates that people must engage in message "elaboration" (developing favorable thoughts about a message's arguments) for long term persuasion to occur (Last, 2001). Exposure theorists study how the intensity of and length of exposure to a message affects behaviour (Perese et al., 2005).
There are basically six stages in a social marketing strategy namely: developing plans and strategies; selecting communication channels and materials based on the required behavioral change and knowledge of the target audience; developing and pretesting materials, typically using qualitative methods; implementing the communication programme or "campaign"; assessing effectiveness in terms of exposure and awareness of the audience, reactions to messages, and behavioral outcomes and refining the materials for future communications. This involves creating a continuous loop of planning, implementation, and improvement (WHO, 2003).
Marketers view the marketing problem as one of developing the right product backed by the right promotion and put in the right place at the right price (Lazars, 1949 communication persuasion strategy and tactics that will make the product familiar, acceptable, and even desirable to the audience. In the case of UHC, fliers, chiefs Barazas (community meetings), announcements in the church, outreaches, women groups, recreational areas electronic and print media targeting specific audiences, thus informing about the upcoming UHC project. It is noted in this study that information about the implementation of UHC was passed to the communities variously. The message was not targeted and the channels were not suitable. For example politicians went round villages telling people to register for UHC using loud speakers on their vehicles, a practice that is synonymous with sensitization during election periods. The interpretation from the community was that UHC was a pathway to steal votes. This inverted messaging minimized acceptability of the programme. Messages by the electronic media was not clear both to the community and health workers and this caused confusion of what UHC was all about. For instance communities did not understand the term "free health care" as it was communicated, and this led them to misinterpret the whole program linking it to "illuminate" (Witchcraft). People's attitude and acceptability for the behavior change also need to be assessed. Their capacity and interest towards the expected behavior change is important. For instance the health workers were not optimally involved in the roll out, time was not negotiated and it was not a bottom-up approach for project ownership and motivation. Among other considerations was the need for problem description and rationale to the health workers followed by strategic team formation and more importantly carry out SWOT analysis. A research plan is important to understand target audiences characteristics, attitudes, beliefs, values and behaviors (Radha, 2011), for example persons who are abled differently, the elderly and the youth-these are audiences with special needs. Development of a marketing strategy becomes critical in order to identify target audience and their specific needs, budget and resource allocation.
Planning for the next course of action-the intervention, in this case develop policies, SOPs and work plans by departmental managers and develop monitoring mechanisms are key areas for the successful UHC implementation. All these parameters would have been captured if social marketing techniques were employed.

Conclusion
There were misconceptions and misunderstanding of what UHC entailed both to the community and to health care workers. Planning and senzitisation was inadequately done and barriers to effective implementation of UHC were noted. The communities were confused about the program and its importance. There is ample evidence to suggest that social marketing can be an effective tool not just in health care treatment but also when introducing a new program in health care, to educate both providers and consumers, just as it has been in health promotion and disease prevention. The evidence on social marketing suggests that its underlying principles of behavior change can be used to influence health care provider behavior and consumer decision making through multiple message strategies and channels. As the remaining 43 Counties of Kenya plan to roll out the UHC program, it is important to adopt the principles of social marketing to improve program outcomes.