Landscape analysis of healthcare policy: the instrumental role of governance in HIV/AIDS services integration framework

Introduction Low and middle-income countries HIV/AIDS interventions are yet to achieve the desired levels of health outcome due to lack of effectiveness and efficiency in programming, a challenge associated with resource limitations, fragmented services, complexities in population and disease characteristics including political landscape. The objective of this study was to establish the instrumental role of governance in the implementation of HIV/AIDS services integration policy framework, with focus on organization structure, participation in decision making, collaboration, stakeholder engagement, political commitment as study variables. Methods Using a mixed method design, a total number of 30 health workers, 5 county AIDS services coordinators (CASCOs), 8 sub-CASCOs and 3 representatives of inter coordinating committee were interviewed in compliance with ethical protocols. Multi-stage sampling techniques was used to select counties in Kenya, health institutions and respondents. Quantitative and qualitative data was generated by administering semi structured questionnaire and key informant interview guide. Results Generated from excel sheet and NVivo software indicate that organization structures existed and clarity and ease of work varied across the different levels of care. Collaboration efforts, however varied, created synergy in policy framework implementation and political commitment complemented the various leadership actions for successful implementation of integration policy framework. Conclusion Governance role is indispensable in the implementation of health policy framework. Policy makers need accurate epidemiological and demographic information to implement contextualized policy framework necessary for sustained improvement in health outcomes.


Introduction
Low and middle-income countries (LMIC) are consistently low in achievement of health outcomes measured by reduction in morbidities and mortalities; responsiveness in healthcare services; risk protection, both social and financial and efficiency in the delivery of healthcare services. The challenges are further compounded by contextual factors such as demographic dynamics in the population, epidemiological and political landscape [1]. In the past four decades, HIV/AIDS has remained a global concern as its ravaging impact continues to be felt among the afflicted population and governments.
In response to the pandemic the has been rapid increase in global partnership with initial stages witnessing vertical and fragmented service delivery in which, for example VCT were stand-alone facility with its own data gathering systems. The existence of separate infrastructures arrangement had major limitations associated huge capital investment with little achievements, Loss-To-Follow-Up (LTFU) in the continuum of care, coupled with missed opportunities in counselling and testing [1,2].
To Improve efficiency, World Health Organization (WHO) and other development partners embarked on swift move to urgently reverse the trend through a scaled approach to provision of antiretroviral therapy. The approach required systematic links across primary, secondary and tertiary healthcare facilities including strengthening home-based care within the countries. Healthcare facilities had a task to deliver ART alongside others services such as, HIV prevention programmes, counseling and testing, prevention of mother to child transmission (PMTCT), tuberculosis (TB), family planning (FP) and any other health services that were essential to optimal antiretroviral treatment [3]. Countries have since responded to integration calls and have adopted various implementation strategies and guideline. For The basic feature of an integrated and effectively operating healthcare institution is one with the ability to maximize the delivery of a range of medical and preventive interventions such as counseling and testing, PTMCT, MCH, FP, ART, Control of TB and STI services, this therefore means, services are packaged and delivered at a single point or co-located alongside other health care services [4]. Principle underpinning integration framework for delivery of quality services to all people, where and when they need, puts emphasis on coordination within health systems, to ensure uninterrupted service delivery. For health managers, this meant increasing access by putting in place strategies that reduce physical distance, financial and administrative barriers, this also required deliberate efforts in community engagement in delivery of treatment and support services [5][6][7].
Literature review, show there is no universal integration framework agreed upon but model success under implementation depended on understanding of contextual factors in utilization of services across the continuum of care [7].
In the same context, countries vary enormously in terms of geography, epidemics, politics, economics and culture that determines the organization of their health systems. Additionally, a country´s health policy framework mirrored social pressures, as well as national values and priorities depending on disease prevalence [8]. To contextualize the study, Figure 1 Illustrates healthcare governance framework and the interrelationship between the various components.
Governance, a guiding principle for integrated services elicits high expectations upon leadership to take technical and political actions to ensure strategic policies exist, formation of collaborations and coalition in systems designs including leveraging resources to reconcile competing demands of limited resources. In order to achieve sustained effort in health systems strengthening, WHO emphasizes on good governance and stewardship as opposed to traditional "command and control" approach among leadership. Good governance, allows public space for active participation and rightly demand for greater say in the management of health services needed.
The result is greater access to services that is appreciated by clients and services provider and so achieving "quality of care we want" becomes a reality and not a dream [1,9,10]. This study explored healthcare governance by four dimensions namely, organizational structure; participation in decision making; collaboration; stakeholder engagement; political commitment and action. Organizational structures are drivers to the implementation of strategies including policies. They define rules, roles and responsibilities that makes it possible to determine feasible and optimal action to be undertaken. Healthcare systems requires high-level coordination of workflow to allow different stakeholders; community, health workers, donors and politicians to harmoniously work together. The workflow describes the hierarchical order and reporting lines and a well-designed structure eliminates potential contradictions likely to arises from confusion in roles, failure to share ideas and conflict arising from complexities in decision making process [11,12]. Classical studies indicated variance in the way power is conferred to citizens and interest groups were unequally distributed [10].  Table 1 shows study counties and Health Facilities. The health workers working in comprehensive care centers who were on duties during the interview days were all included in the study. Data analysis: analysis of quantitative and qualitative data was done concurrently. Quantitative data from health worker questionnaire captured using open data kit (ODK) were cleaned and made available for analysis on excel sheet. The summary data, were presented as charts and graphs and mainly describing trends of an events in healthcare institution. Qualitative data from KIIs were coded both manually and using N-VIVO computer programme. The study adopted a systematic approach of reducing qualitative data, categorizing data based on study or emerging themes and patterns after analysis of specific statements. Mapping and interpretation of the texts was done to identify meaningful and relevant findings, which was reported as a blend of extract narratives or excerpts of the condensed meanings or quotes that provided evidence to support the study claims where necessary.
Page number not for citation purposes 4 Ethical consideration: since the study dwelt on a sensitive area of healthcare provision, prior approval from scientific review committee was sought and obtained. The work ethic and rights of all the institutions involved were respected and they provided a written permission before commencement of the study. Full disclosure on study purposes, benefits risks was done at institutional and individual respondent level. Participation in the study was voluntary and respondents we given opportunity to a written consenting process.
Anonymity and confidentiality were observed through the entire study process as the respondents were tagged to unique identifiers.

Results
Organisation structure and operations: results in Figure 2 describe organization structure existence, clarity of such structure and ease of work within such structure. The response indicated consistency that organization structures do exists in the different level of service delivery ranging 89-92% at health centre to county referral level. Clarity of structure was witnessed to have an increase in ascending order from health centre to county (70-87%), while ease of work was reported to be high (70%) at health centre level and decreased systematically to sub-county level and to county level with 66% and 62% respectively.
When key informants were asked about organisation structure and  Because to offer that service in one room. It becomes cost effective and efficient to the patient. " MSA 3. '''there are some challenges that have risen in terms of the personnel. In terms of the service providers, there is shortage of drugs so the needs of the clients are not fully met... " ISL 1. "...patients are able to get services at one point, but maybe because of issues around infrastructure and staffing some are forced maybe to walk from MCH maybe to the lab or pharmacy. So just because of infrastructure and issues around staffing, we can´t or maybe we do not offer enough." LTK 1.

Discussion
Health centres and hospitals both at sub-county and county level had a consistent response in existence of organizational structure on a positive note. This is an indicator of maturity in health system strengthening, attributable to efforts in devolution and implementation of integration frameworks. The two approaches confer autonomy to different level of healthcare institutions to perform specific functions which translates to some level of ownership and Page number not for citation purposes 6 automatically invoking implementation of management structures [1,16]. Clarity of organization structure were at different level across levels of care, health centres experienced lesser appreciation and an upward trend observed towards hospital at subcounty and county level. Hospitals, have more functional roles, bigger resource capacity and a larger population accessing healthcare services hence there is deliberate effort to have a more differentiated and clear structure for efficient operations [17][18][19]. Ease of work with the existing structure was more evident at lower levels of care compared to hospitals at sub county and county level.
In concurrence with existing literature, larger organization with more functional roles have an increase in hierarchical structure, which in most cases are cumbersome and may be non-responsive to dynamics that are common in health systems hence the complexity in work environment [20]. Overall, there study provides evidence that organization structure at all levels of care, play a key role in providing directions and contextual interaction with the health system that is important in access of healthcare services [21]. Majority (80%) of the healthcare institution made deliberate effort to contact and make follow up with partners in the collaborative circles. Partnership is seen to have created synergy in the implementation of integration framework, particularly in Human Resources for Health (HRH) and Health Information System (HIS). Hospitals at county and referral level had more collaborative arrangement compared to health centres.
Similarly, the capital Nairobi and Homabay had more collaborative arrangements. This can be directly linked to high resources needs given the population numbers and prevalence [22][23][24][25][26].
Collaboration had a highly coordinated multisectoral dimension and was mainly between health institution, particularly when making referrals and involvement of donor agencies in the various aspects of treatment and care. Level of participation in decision making was averagely high at 56% and the remaining, near half either reported medium level of participation or neutral. The perception on nonrepresentation in decision making was drawn to the fact that most resources needs were not met as per the request and their opinion was not reflected in the final decision. More so, the community engagement was done through Community Health Volunteers (CHVs).
Lack of total involvement of HW, community and patient undermine the principle of sustainable improvement in the delivery quality care to population in need [27].
Commitment and political influence proved to be key leadership roles in reduction of stigma and successful implementation of global health policies geared toward improved access of health care services [28][29][30]. This study draws evidence of in-depth engagement of leadership in political and technical action to improve access healthcare services particularly PMTCT. The commitment goes further to ensure implementation of context specific policy frameworks which is likely to be reflected in quality care and improved maternal health outcome.
Integration framework intend to deliver services in consolidated approach for purposes of effectiveness and efficiency, which has been achieved to some extent. However

Competing interests
The author declares no competing interests.

Authors' contributions
Maureen Atieno Adoyo played a key role in conceptualization, designing of the study, played active role in conducting interviews and finally manuscript preparation.