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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 3, May/June 2018
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Discussion
This qualitative research study describes facilitators of, barriers
to and context of ACS care at Kenyatta National Hospital.
The most prominent facilitators mentioned by the majority of
participants highlighted that Kenyatta National Hospital is one
of two main public referral and teaching centres with the highest
capability for ACS diagnostics and therapeutics, including the
only public hospital with a cardiac catheterisation laboratory,
expert consultants such as cardiologists, and cardiac surgery.
However, all participants highlighted that there are several
facility-, provider- and patient-level barriers to optimal ACS
management. At the facility level, sub-optimal diagnostic
capabilities, especially the very limited number of ECG machines
in the hospital, was listed as one of the most significant
barriers to making prompt diagnosis when ACS is suspected. A
limited supply of thrombolysis medications and adaptation of
standardised ACS protocols were listed as additional barriers.
All participants had positive attitudes towards both checklists
and audit and feedback systems as key tools to improve ACS
care. Some participants described existing checklists such as
ICU, tuberculosis or trauma care checklists as examples that a
toolkit for improvement of quality of ACS care that included
checklists could be feasibly incorporated at the hospital.
We know of no other studies from sub-Saharan Africa that
have evaluated facilitators of, barriers to and context of ACS
care, using qualitative research methods. There are similar
studies from high-income and other low- and middle-income
countries that have used qualitative research as a tool to guide
future targets and tailor solutions to improvement of quality of
care. For example, a 2001 qualitative study at eight US hospitals
explored initiatives, strategies and approaches to improvement
of care for patients with acute myocardial infarction. This
study showed that shared goals for improvement, substantial
administrative support, strong physician leadership, and use
of credible feedback data were mechanisms used in hospitals
that improved their processes of care, such as medication use,
compared to those that did not.
9
Themes from a 2010 study in Egypt, which assessed barriers
and opportunities to implement an ACS registry included the
need to build a culture of applied research, the importance of
modelling a blame-free culture, and the potential of clinical
registries as cost-effective investments to support improvement
in quality of care for ACS in low- and middle-income countries.
Limited human resources and technical infrastructure were two
key constraints identified.
10
A 2016 qualitative study from Kerala, India, evaluating
pre-hospital ACS care has been useful in identifying areas for
improvement of quality in pre-hospital ACS care.
4
The study
found lack of recognition of ACS symptoms that warrant
emergent evaluation, high cost of ACS treatment, specifically
cardiac catheterisation, insufficient transport systems, and
infrequent use of medical emergency services by the public as
contributors to pre-hospital delays.
4
The framework of the WHO’s health system building blocks
consists of service delivery, health workforce, health information
systems, access to essential medicines, financing and leadership
as key target components of improving access to quality
healthcare.
2
This framework can be used to place our results into
context. For example, service delivery requires accurate diagnosis
for appropriate management, which highlights the primacy
of functioning ECG machines for improving ACS care. The
WHO includes ECGs as an essential diagnostic technology in
its package of essential non-communicable disease interventions
(PEN), and therefore they should be a priority for improving
ACS care.
11
Another example is the need for a health information system
to build the evidence base and plan for appropriate and timely
allocation of healthcare providers and treatment. An audit
and feedback system for ACS and other acute cardiovascular
conditions would be one potential mechanism to strengthen
the Kenyan health system for better ACS performance and
outcomes. The WHO also recommends a comprehensive human
resources information system to monitor the health workforce
to assess needs and guide appropriate training and utilisation of
the health workforce.
Notably, these interviews were conducted during a period
when there was a nationwide physician strike in Kenya that
lasted 100 days and affected public institutions, including
Kenyatta National Hospital.
12
A physician strike shows the
potential fragility of low- and middle-income country health
systems and the challenges in improving quality and safety.
In terms of financing, Kenya spends 6.4% of its gross
domestic product on healthcare, which is relatively low compared
with global peers.
13
However, 40% of this spending comes from
government sources. Future expansion of Kenya’s healthcare
expenditures, particularly in the context of achieving universal
access to healthcare, will need to account for the growing disease
burden of ischaemic heart disease, its acute manifestations such
as ACS, and underlying risk factors, to create a sustainable,
responsive, high-quality health system that offers financial
protection to its citizens.
Our study has some limitations, including being a single
location at a public referral hospital; however, ours is the first
study of its kind in the region. Another major limitation of
this study is that we did not include patients among those
interviewed, which is an area of future research for our team.
We plan to explore patients’ perspectives in areas of pre-hospital
delay, patients’ knowledge about ACS, experiences in receiving
ACS-related care and patients’ medical costs.
Conclusions
This qualitative research assessed facilitators of, barriers to
and context of ACS care at Kenyatta National Hospital. These
results provide the novel perspectives of healthcare providers on
the current trends of ACS management, and potential areas of
limitations and opportunities to improve ACS care and outcomes.
MDH receives grant support from the World Heart Federation to serve as
its senior programme advisor for the Emerging Leaders programme. This
programme is supported by unrestricted educational grants from Boehringer
Ingelheim and Novartis, with previous support from AstraZeneca and Bupa.
Funding was provided by Fogarty International Center TW R25TW009345
and the Tibar Fabian award from the University of California, Los Angeles.
References
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Hertz JT, Reardon JM, Rodrigues CG, de Andrade L, Limkakeng
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