ASSESMENT OF EFFECTIVENESS OF HEALTHCARE DELIVERY IN RURAL AREAS: A STUDY OF

WUNDANYI IN TAITA TAVETA COUNTY

SMC 201/2025

A research project submitted to department of training in partial fulfillment for certificate in

Senior Management Course at The Kenya School of Government.

July 2025.

Declaration
We the members of the senior management course No SMC 201/2025 declare that this
research project study is our original work and has not been presented for any award in any
other institution of higher learning or body of examination prior to this time.
Name………………………...…………………. reg no………………………. sign…………………. date………………….
ANN KARIMI MWARUKA
BENJAMIN KABUGA NDUNG’U
EVA KEMUNTO MAGETO
FERDINARD WANGIRA OPAKA
JANE WANJUKU KARANJA
MARTIN MURIMI MBAE
PHEDINIKE MAMBORI MWAMINO

DECLARATION BY THE SUPERVISOR

I confirm that the work report of this project was carried out under my supervision.

Florence (MS)

Signature…………………………….

Date ………………………………...

Dedication
We dedicate this project to our families, employers, and KSG fraternity for your immense
support towards the realization of this great project and throughout the period of study.

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Acknowledgements
We thank God for the strength and patience he has accorded us throughout our study process.
Special thanks to our families for giving us humble time during our study period and to our
various organization special thanks for granting us opportunity of attending senior management
course. Also, we wish to appreciate our supervisor for having made available time to guide us
through the project writing.

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Table of contents

Declaration......................................................................................................................................i
Dedication...................................................................................................................................... ii
Acknowledgements.......................................................................................................................iii
Table of contents...........................................................................................................................iv
List of figures................................................................................................................................. vi
List of tables................................................................................................................................. vii
Abbreviations.............................................................................................................................. viii
Abstract......................................................................................................................................... ix
CHAPTER ONE: INTRODUCTION.....................................................................................................1
1.0 Overview.............................................................................................................................. 1
1.1 Background.......................................................................................................................... 1
1.2 Statement of the Problem....................................................................................................2
1.3 Objectives of the study........................................................................................................ 3
1.4 Research Questions..............................................................................................................4
1.5 Assumptions........................................................................................................................ 4
1.6 Justification of the study......................................................................................................4
1.7 Significance of the Study......................................................................................................5
1.7.1 Policy Makers................................................................................................................ 5
1.7.2 County Health Officials..................................................................................................5
1.7.3 Development Partners and NGOs.................................................................................6
1.7.4 Rural Communities and Local Leaders..........................................................................6
1.7.5 Researchers and Academic Institutions.........................................................................6
1.8 Scope................................................................................................................................... 6
1.9 Limitations of the Study.......................................................................................................7
CHAPTER 2: LITERATURE REVIEW.................................................................................................. 8
CHAPTER 2: LITERATURE REVIEW...............................................................................................8
2.0 Introduction......................................................................................................................... 8
2.1 Theoretical Framework.................................................................................................... 8

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 2.1.1 Andersen Behavioral Model..........................................................................................8
2.1.2 Systems Theory.............................................................................................................9
2.1.3 Integration of Andersen Model and Systems Theory....................................................9
2.2 Review of Empirical Studies...............................................................................................10
2.2.1 Transport accessibility.................................................................................................10
2.2.2 Availability of Medics and Specialists..........................................................................10
2.2.3 Availability of Medical Equipment and Essential Drugs...............................................11
2.2.4 Availability of power/electricity..................................................................................12
CRITICAL ANALYSIS OF EMPIRICAL STUDIES AND RESEARCH GAP............................................13
2.3.1 RESEARCH GAPS..............................................................................................................14
CONCEPTUAL FRAMEWORK.....................................................................................................14
CHAPTER 3: RESEARCH METHODOLOGY......................................................................................15
3.0 INTRODUCTION..................................................................................................................15
3.2 Research Design.................................................................................................................15
3.3 Study Area..........................................................................................................................16
3.4 Target Population...............................................................................................................16
3.5 Sampling Technique and Sample Size.................................................................................16
3.6 Data Collection Methods................................................................................................... 17
3.7 Data Analysis......................................................................................................................17
3.8 Ethical consideration..........................................................................................................17
References................................................................................................................................... 18
APPENDIX A: INTRODUCTION LETTER..........................................................................................20
APPENDIX B: QUESTIONNAIRE.....................................................................................................21

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List of figures

vi
List of tables

vii
Abbreviations
MOH-Ministry of Health

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Abstract
 Centered (Justified)
 Single Spacing
 Must fit in one page
 No denting of paragraphs
 Should contain summary of every step in one sentence i.e. title, statement of the
problem, objective, research design, sampling technique.

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CHAPTER ONE: INTRODUCTION
1.0 Overview
This chapter introduces the study on the assessment of the effectiveness of healthcare delivery
in Wundanyi Sub-County, Taita Taveta County, Kenya. It begins by presenting the background of
the study, offering a global-to-local perspective on healthcare delivery and highlighting key
issues affecting rural health systems. The chapter then outlines the statement of the problem,
identifying the gap between the ideal state of healthcare delivery and the current challenges
faced in Wundanyi. The research objectives and corresponding research questions are clearly
stated to guide the inquiry, focusing on four key variables: transport accessibility, availability of
medics and specialists, availability of drugs and equipment, and access to electricity.
Assumptions underpinning the study are outlined, reflecting expected constants during the
research period. The justification section explains why the study is necessary, emphasizing the
need for localized evidence to improve health service delivery. The significance of the study is
discussed in terms of its potential beneficiaries, including policymakers, health administrators,
and researchers. The scope of the study is defined in relation to content, location, and
timeframe, while limitations beyond the researcher’s control are acknowledged and mitigation
measures stated. Finally, key operational terms used in the study are clearly defined to ensure
consistency and clarity throughout the research process.
1.1 Background
Effective healthcare delivery refers to the provision of accessible, timely, equitable, and high-
quality health services that improve patient outcomes and population health. Globally, the
effectiveness of healthcare systems has increasingly come under scrutiny due to rising
healthcare costs, disparities in access, and changing disease patterns. Innovations such as digital
health technologies, machine learning, and integrated service delivery models are being
explored to address inefficiencies and enhance outcomes. According to Thetic (2024), machine
learning models have revolutionized cost-effective healthcare delivery by improving diagnostic
accuracy, patient monitoring, and health resource allocation globally.
In recent years, the global healthcare community has shifted focus from infrastructure
expansion alone to a broader understanding of efficiency, patient-centered care, and evidence-
based practice. Aldhumayri et al. (2024) emphasize that innovative healthcare delivery
approaches—such as decentralization, telemedicine, and community-integrated services—are
essential for addressing modern challenges like ageing populations, chronic diseases, and health
inequities. Evidence-based practice, as highlighted by Connor et al. (2023), not only improves
patient outcomes but also maximizes return on investment in health systems. However, as
Nuckols (2024) argues, the success of these innovations depends largely on contextual
implementation factors.
In Sub-Saharan Africa, healthcare systems often face persistent barriers including inadequate
infrastructure, poor workforce distribution, limited drug availability, and erratic power supply.
Babalola and Moodley (2020) found that healthcare facilities in the region often suffer from low
efficiency due to resource constraints and managerial challenges. Ampomah et al. (2020)
further noted that integrated health systems in Africa show promise in improving health service
outcomes, especially in rural and underserved areas, if implemented effectively. Nonetheless,
the reality in many African countries reveals fragmented systems and inconsistent healthcare
outcomes (Omam et al., 2023).
Kenya, in its quest to improve healthcare access and efficiency, embraced devolution in 2013,
transferring significant responsibility for healthcare delivery to county governments. This
restructuring aimed to bring services closer to communities, enhance responsiveness, and
address regional disparities. Studies by Masaba et al. (2020) and Nyawira et al. (2022) confirm
that while devolution has improved access to some extent, challenges persist in human
resource management, infrastructure distribution, and inter-county coordination. Zeng et al.
(2022) and Moses et al. (2021) argue that county-level disparities in performance continue to
undermine national health goals, with some counties like Wundanyi Sub-County lagging behind
in key indicators.
In the Kenyan context, multiple factors influence the effectiveness of healthcare delivery,
including transport accessibility, availability of skilled personnel, medical supplies, and
supporting infrastructure like electricity. A study by Juma and Kihara (2023) in Makueni County
identified transport systems, availability of equipment, and workforce motivation as critical
determinants of efficient service delivery. Miriti (2016) also observed that devolution
introduced mixed outcomes in hospital-level healthcare provision, with peripheral regions
struggling to meet national healthcare standards.
Wundanyi Sub-County, situated in the hilly terrains of Taita Taveta County, faces unique
challenges related to terrain, road infrastructure, and workforce distribution. Although the
government has made strides in expanding healthcare infrastructure in the region, anecdotal
evidence and preliminary assessments suggest persistent inefficiencies in service delivery. For
example, long travel distances, power outages, staff shortages, and irregular drug supply are
frequently cited as barriers by local residents and health officials alike. These issues resonate
with the disruption factors described by Fatani et al. (2024), who argued that system-level
shocks such as infrastructural breakdowns significantly impact healthcare effectiveness in
underserved communities.
Understanding the effectiveness of healthcare delivery in Wundanyi thus requires a
multidimensional approach that considers logistical, human, and systemic factors. As Signé
(2021) highlights, the Fourth Industrial Revolution offers an opportunity for Africa to bridge the
gap between healthcare promise and reality but only if the foundational challenges are first
addressed. This study seeks to assess how specific variables transport accessibility, availability of
medics and specialists, availability of drugs and equipment, and access to electricity—
collectively affect healthcare delivery in Wundanyi Sub-County. By doing so, it contributes to
ongoing efforts to enhance equitable, efficient, and sustainable health systems in Kenya.
1.2 Statement of the Problem
In an ideal healthcare system, all citizens should have equitable access to quality, timely, and
affordable health services regardless of their geographic location. Effective healthcare delivery
should be characterized by well-distributed health facilities, skilled personnel, reliable supply of

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medical commodities, and essential infrastructure such as transport and electricity. Globally,
countries are adopting innovative, evidence-based approaches to optimize healthcare delivery
and improve patient outcomes (Connor et al., 2023; Aldhumayri et al., 2024). Machine learning
and digital transformation, for instance, are now being applied to enhance efficiency and reduce
operational costs (Thethi, 2024). In such systems, healthcare access is not limited by terrain,
power outages, or staff shortages.
However, in practice particularly in rural and under-resourced areas such as Wundanyi Sub-
County in Taita Taveta County these ideal conditions are far from reality. Despite devolution and
the government's effort to decentralize healthcare services, challenges persist. Studies have
shown that rural counties in Kenya struggle with inadequate road infrastructure, insufficient
medical personnel, intermittent drug supplies, and unreliable electricity (Masaba et al., 2020;
Nyawira et al., 2023). For example, Zeng et al. (2022) found that counties with weak logistical
support and infrastructural limitations underperform in health outcomes, particularly maternal
and child health indicators.
In Wundanyi Sub-County, these challenges are compounded by its rugged terrain, poor
transport connectivity, and uneven distribution of health workers. Residents often travel long
distances on poor roads to access basic health services, while health facilities frequently report
stockouts of essential drugs and equipment. As Fatani et al. (2024) observed, such system-level
disruptions significantly impact service delivery effectiveness, particularly in remote settings.
Furthermore, power instability hampers the storage of vaccines, operation of diagnostic
machines, and emergency services limiting the functionality of health centers in the region
(Juma & Kihara, 2023).
Despite numerous policy frameworks aimed at achieving Universal Health Coverage (UHC),
there is limited empirical evidence on how these structural and logistical challenges specifically
affect healthcare delivery effectiveness in Wundanyi Sub-County. Most existing studies focus on
broader county-level performance (Moses et al., 2021; Nyawira et al., 2022), leaving a gap in
localized research that can inform targeted interventions at sub-county level. Without such
data, policy and funding decisions may fail to address the actual service bottlenecks
experienced in rural areas.
Therefore, this study seeks to fill this gap by assessing the effectiveness of healthcare delivery in
Wundanyi Sub-County, focusing on four critical variables: transport accessibility, availability of
medics and specialists, availability of drugs and medical equipment, and access to
power/electricity. The purpose is to generate context-specific evidence to inform resource
allocation, infrastructure development, and policy design for improved health outcomes in
similar rural settings.

1.3 Objectives of the study

The general objective of this study is to assess the effectiveness of healthcare delivery in
Wundanyi Sub-County, Taita Taveta County, Kenya. The specific objectives are:

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 1. To evaluate the influence of transport accessibility on the effectiveness of healthcare
delivery in Wundanyi Sub-County.
2. To assess the effect of the availability of medics and specialists on healthcare delivery in
Wundanyi Sub-County.
3. To examine how the availability of drugs and medical equipment affects the
effectiveness of healthcare delivery in Wundanyi Sub-County.
4. To determine the impact of access to power/electricity on the effectiveness of
healthcare delivery in Wundanyi Sub-County.
1.4 Research Questions
1. How does transport accessibility influence the effectiveness of healthcare delivery in
Wundanyi Sub-County?
2. What is the effect of the availability of medics and specialists on healthcare delivery in
Wundanyi Sub-County?
3. In what ways does the availability of drugs and medical equipment affect the
effectiveness of healthcare delivery in Wundanyi Sub-County?
4. How does access to power/electricity impact the effectiveness of healthcare delivery in
Wundanyi Sub-County?
1.5 Assumptions
This study is based on the following assumptions:
1. The four key variables transport accessibility, availability of medics and specialists,
availability of drugs and equipment, and access to power/electricity remain relatively
constant during the data collection period and are not significantly affected by sudden
policy changes, natural disasters, or external disruptions.
2. The healthcare infrastructure in Wundanyi Sub-County has not undergone major
changes immediately before or during the study, ensuring that observations reflect
typical conditions.
3. The respondents have adequate knowledge of the healthcare delivery system in their
locality and are willing to respond truthfully.
4. A pre-survey conducted within the Sub-County established the stability and relevance of
these assumptions, thereby guiding the delimitation of the research focus.
1.6 Justification of the study
Persistent inefficiencies in rural healthcare delivery undermine both population health and local
economic productivity. International evidence demonstrates that inadequate transport links,
shortages of skilled personnel, unreliable power, and stock-outs of essential medicines elevate
preventable morbidity and mortality and increase treatment costs for already vulnerable
households (Aldhumayri et al., 2024). In Sub-Saharan Africa, such bottlenecks depress labor
participation and household earnings, deepening poverty cycles (Ampomah et al., 2020).
Kenya’s commitment to Universal Health Coverage (UHC) will remain aspirational unless
practical solutions address these structural barriers at the community level. By systematically
analyzing how transport accessibility, workforce availability, medical supplies, and electricity
affect service performance in Wundanyi Sub-County, this study targets factors shown globally to

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deliver the greatest returns on health investments and socio-economic development
(Thethi, 2024).
Despite a decade of devolution meant to promote equitable healthcare, empirical work in Kenya
has concentrated on county-level averages, masking substantial intra-county disparities. Studies
in Meru, Makueni, and national samples consistently link poor roads, erratic power, and
human-resource gaps to weak hospital performance (Masaba et al., 2020; Miriti, 2016;
Juma & Kihara, 2023). Mixed-methods assessments find that counties with rugged terrain and
diffuse settlements, like Taita Taveta, often underperform on key indicators such as skilled-birth
attendance and commodity availability (Zeng et al., 2022; Moses et al., 2021). However, no
peer-reviewed study has yet produced granular, sub-county-specific evidence for Wundanyi,
leaving planners to rely on anecdotal reports when allocating resources. This empirical gap
weakens the precision of budgeting, supply-chain design, and workforce deployment within the
county (Nyawira et al., 2022; Nyawira et al., 2023).
Generating context-specific data for Wundanyi will therefore guide evidence-informed policy,
investment, and practice. Findings will help county health authorities prioritise road
maintenance to high-burden catchments, upgrade power solutions for cold-chain integrity, and
rationalise staffing models—actions shown elsewhere to enhance service efficiency and patient
satisfaction (Nuckols, 2024; Fatani et al., 2024). Moreover, the study will contribute to Kenya’s
broader agenda of leveraging Fourth-Industrial-Revolution opportunities by identifying
foundational bottlenecks that must be resolved before digital innovations can scale effectively
(Signé, 2021). The resulting recommendations will support national and county governments,
development partners, and researchers seeking scalable interventions to advance UHC targets
and Sustainable Development Goal 3 across comparable rural settings.
1.7 Significance of the Study
Effective healthcare delivery remains a critical component of social and economic development,
particularly in rural areas where populations often face multiple systemic barriers. This study,
focusing on Wundanyi Sub-County in Taita Taveta County, may offer practical and scholarly
contributions that extend across various stakeholder groups. By examining four key
determinants transport accessibility, availability of medics and specialists, availability of drugs
and equipment, and access to power the study may generate actionable insights that can shape
health policy, planning, and research. The following subsections outline the potential
significance of the study to key actors involved in healthcare delivery and development.
1.7.1 Policy Makers
This study may provide valuable evidence to inform future policy formulation and review by
both national and county governments. By identifying specific barriers to healthcare delivery in
rural areas such as poor transport networks, lack of qualified personnel, limited medical
supplies, and inadequate power infrastructure the findings may support the development of
policies that are responsive to the unique challenges of rural communities. Policymakers may
use this evidence to design inclusive, equitable, and sustainable health systems that align with
Kenya’s Universal Health Coverage (UHC) agenda.

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1.7.2 County Health Officials
The study may serve as a practical planning tool for county health departments, particularly in
Taita Taveta County. It may help health administrators assess gaps in service delivery and inform
strategic decisions regarding resource allocation, infrastructure development, and staffing. By
highlighting locally relevant data on healthcare challenges, the study may enable county officials
to prioritize investments in areas that directly impact service quality and access, such as
transport accessibility, electricity provision, and availability of drugs and specialists.
1.7.3 Development Partners and NGOs
For non-governmental organizations and international development agencies, the study may
provide critical insights needed to design evidence-based interventions in rural healthcare. The
findings may help these stakeholders align their health programs with real community needs,
ensuring that donor-funded initiatives are targeted, impactful, and sustainable. This may
enhance collaboration with government actors and increase accountability in health sector
investments.
1.7.4 Rural Communities and Local Leaders
The study may amplify the voices of rural residents by capturing their lived experiences and
challenges in accessing healthcare. Community leaders and members may use the findings to
advocate for improvements in local health services and infrastructure. Involving communities in
interpreting and responding to the study results may also strengthen their participation in
healthcare planning and promote local ownership of development initiatives.
1.7.5 Researchers and Academic Institutions
This study may contribute to the growing body of literature on rural health systems in Kenya
and Sub-Saharan Africa. By offering a focused analysis of Wundanyi Sub-County, it may serve as
a reference point for comparative studies, case-based teaching, and further academic
exploration into healthcare delivery in similar settings. It may also highlight new areas for
interdisciplinary research, such as rural infrastructure, public health policy, and community
health systems.
1.8 Scope
The scope of this study is confined to assessing the effectiveness of healthcare delivery in
Wundanyi Sub-County, Taita Taveta County, Kenya, with a focus on rural populations. The study
examines four independent variables transport accessibility, availability of medics and
specialists, availability of drugs and equipment, and access to power/electricity and their impact
on three dependent variables: access to healthcare, quality of healthcare services, and patient
satisfaction. The research targets rural residents of Wundanyi Sub-County, encompassing
individuals across all age groups, genders, and socio-economic backgrounds to ensure a
representative sample. Data will be collected from primary healthcare facilities, including
dispensaries and health centers, within the sub-county. The study will employ a mixed-methods
approach, combining quantitative data from surveys and qualitative insights from interviews
and focus group discussions with community members, healthcare workers, and local
administrators. The geographical scope is limited to Wundanyi Sub-County, though findings may

6
have implications for other rural areas in Taita Taveta County and similar settings in Kenya. The
study period covers recent data and experiences to reflect current challenges and opportunities
in healthcare delivery.

1.9 Limitations of the Study

This study faces several limitations that may affect its outcomes and generalizability. Firstly, the
focus on Wundanyi Sub-County may limit the applicability of findings to other regions with
different geographical, cultural, or economic contexts, even within Taita Taveta County.
Secondly, the availability and accuracy of data may be constrained by incomplete health facility
records, underreporting, or reluctance among respondents to share sensitive information about
healthcare experiences. Thirdly, logistical challenges, such as poor road networks and limited
access to remote areas within the sub-county, may hinder comprehensive data collection,
particularly during adverse weather conditions.
Additionally, the study’s reliance on self-reported data for patient satisfaction and healthcare
quality may introduce biases, as perceptions of care can be subjective and influenced by
individual expectations or cultural factors. The limited availability of specialists and advanced
medical equipment in rural facilities may also restrict the depth of analysis regarding specialized
care. Lastly, time and resource constraints may limit the sample size and the ability to conduct
longitudinal assessments, potentially affecting the robustness of conclusions. Despite these
limitations, the study will employ rigorous methodologies to ensure reliable and actionable
findings.

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CHAPTER 2: LITERATURE REVIEW
CHAPTER 2: LITERATURE REVIEW
2.0 Introduction
The chapter aims to review the theoretical framework, empirical studies, Critical Analysis of
Empirical Studies, research gap, and Conceptual Framework that will inform the study. The link
between variables is examined.
2.1 Theoretical Framework
The study is deeply rooted in two well-established theories: Andersen's Behavioral Model and
Systems Theory, both of which play a pivotal role in shaping our understanding of healthcare
access in rural areas.
2.1.1 Andersen Behavioral Model
The Andersen behavioral model, first developed by Ronald Andersen in the late 1960s, remains
one of the primary tools for studying why people use or do not use health services (Andersen,
1995) It sorts the reasons people visit a clinic into three neat buckets:
1. Predisposing Factors: Personal traits that shape the choice to seek care, like age, sex,
education level, marital status, and deep-seated cultural ideas.
2. Enabling Factors: Practical resources that either open a door or slam it shut, including
money, a working car, health insurance, nearby clinics, and enough doctors or nurses on
the payroll.
3. Need Factors: Both what a patient feels are wrong and what a doctor decides after
looking at a patient.

Figure 1: Andersen model

In many rural areas, such as Wundanyi, enabling resources—such as spacious roads, stable
power, stocked medications, and expert medical care—are still scarce. These gaps limit practical
access and drain people's eagerness or chance to find treatment. The Andersen model thus
helps explain how the supply of resources shapes health delivery, especially where obstacles are
built into the system and in the minds of the patients.
2.1.2 Systems Theory

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Systems Theory traces its roots to Ludwig von Bertalanffys work in the 1940s and has since
found a home in fields such as healthcare (Bertalanffy, 1968). The core idea is simple: any
organized set of parts within an institution or a national health network is better when its
people, tools, rules, and resources act as a cohesive, unified unit aimed at shared goals.
The healthcare system encompasses governance bodies, clinical staff, physical facilities, drug
and equipment supply chains, records systems, and financial management (WHO, Primary
health care systems: Case study from Kenya, 2020). That mix is fragile; if power cuts or poor
stock management hit one piece, even a well-trained team can deliver disappointing care. In
practice, clinics with skilled workers still fall short when lifesaving machines sit idle because
electricity flickers or key medicines are unavailable.
Applied to Wundanyi, the model illustrates precisely how transport accessibility, availability of
medics and specialists, availability of drugs and equipment, and availability of power/electricity
interact to influence all patient visits. Picture a busy health post with skilled nurses and doctors:
it can still fall short if there is no light, running water, or dependable stock of bandages and
painkillers, proving again that strength in one area cannot mask weakness in another.
2.1.3 Integration of Andersen Model and Systems Theory
When the Andersen Behavioral Model and Systems Theory are combined, they provide a
practical framework for examining how people in the rural Wundanyi subcounty access health
services. The Andersen Model guides the steps that lead a person from contemplating care to
stepping into a clinic. At the same time, Systems Theory demonstrates how factors such as
nearby hospitals, supply chains, staff shortages, or even government policy can influence the
process, making it more or less welcoming.
Using both models’ side by side also makes it possible to look at the problem from two different
heights:
At the micro level, Andersen identifies community and personal factors, such as household
income, local customs, and the individual's perception of the severity of an illness, any of which
can delay or expedite a visit to a provider.
At the macro level, Systems Theory widens the frame to encompass organizational issues and
physical infrastructure — things like stock-outs of medicines, staffing rules, poorly routed
motorbike trails, and unreliable electricity — that quietly shape every patient experience, even
if no one speaks about them directly.
When viewed together, these lenses provide a comprehensive picture of how health care is
reaching people in Wundanyi subcounty. They also highlight practical changes that can enhance
both patients' day-to-day experiences and the system as a whole, underscoring the
thoroughness of our research.

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2.2 Review of Empirical Studies
2.2.1 Transport accessibility
(Essendi, 2015)emphasized that both travel time and transportation costs were significant
predictors of late healthcare visits, particularly among low-income families.
(Ndirangu, 2022) Examined transport-related issues with immunization in remote areas of Taita
Taveta and Kwale counties. The study found that children living more than eight kilometers
away from health facilities were significantly less likely to complete their vaccination schedules,
particularly in areas without regular public transportation.
(Maina, 2021) It was found that approximately 60% of rural households in six Kenyan counties
were located more than five kilometers away from the nearest health facility. Poor road
infrastructure has significantly limited access to maternal healthcare, especially for women. A
study on maternal health access in Western Kenya (Githeko, 2020) Employed a mixed-methods
design, combining focus group discussions and semi-structured interviews with health staff and
expectant mothers. Findings revealed that during the rainy season, most women were unable to
travel to healthcare facilities due to flooded roads and the unavailability of public
transportation.
(Owino, 2020) pointed out logistical challenges as a significant impediment to healthcare
delivery in rural areas. He states that there is inadequate transport infrastructure and that
medical supplies are often delayed in reaching the facility. In this qualitative study, informant
interviews were conducted with facility managers and pharmacists to gain insight into their
perspectives on the frequent disruptions to supply chains, particularly in remote counties where
roads are often impassable. (Chesire, 2021)Through a combination of methods, including facility
surveys and interviews with healthcare workers and patients, the study discovered that health
workers have been facing difficulties with community outreach and emergency referrals due to
poor terrain and a lack of vehicles.
2.2.2 Availability of Medics and Specialists
According to the World Health Organization (WHO, 2016) report on the distribution of the
health workforce, only 24% of the total health workforce serves more than 50% of the world's
population that lives in rural areas. The WHO report employed comparative statistical methods
to illustrate global disparities in doctor-patient ratios, particularly in low-income regions,
utilizing secondary data analysis from national health databases in 60 countries. Targeted
training, deployment, and retention tactics that are suited to rural settings were recommended
in the report.
(Namazzi, 2019) evaluated the impact of a lack of human resources on maternal health
outcomes in rural districts of Uganda. Namazzi used staff interviews and checklists to gather
data from 18 healthcare facilities, employing a descriptive cross-sectional design. Researchers
found that in many rural health centers, only one or two nurses were responsible for handling
all maternal and neonatal care, leading to service delays and preventable complications. For
interpretation, the study employed trend comparison and frequency analysis.

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According to Ministry of Health report (MOH, 2022), Kenya's rural counties have fewer than 10
doctors per 100,000 residents, which is significantly lower than the WHO-recommended
threshold of 44.5 per 10,000. The report analyzed staffing gaps across counties using statistical
modeling based on national data on the health workforce. Due to the lack of specialists, Taita
Taveta, for example, has been found to rely primarily on nurses and clinical officers, which
restricts the range of services available at rural facilities.
(Mutinda, J., & Wamalwa, C, 2019)Mutinda and Wamalwa (2019) examined the factors that
influence the retention of medical professionals in rural Kenya. The researchers conducted semi-
structured interviews with physicians and nurses in Kitui and Kakamega counties, employing a
qualitative case study design. Their thematic analysis revealed that insecurity, limited career
advancement opportunities, and housing shortages were the primary obstacles to retention.
The study concluded that unless work conditions are improved, rural staffing will remain
unsustainable.
To evaluate staffing adequacy across sub-county hospitals in Taita Taveta County, (Kahiga, Health
workforce gaps in sub-county hospitals: A study of staffing adequacy in Taita Taveta, 2021) carrie
d out a facility-based descriptive study. The researchers found that the majority of rural facilities
operated with a staff-to-population ratio significantly below national targets, as determined
using facility audit tools and HR records. To address the staffing shortage, the study employed
descriptive analysis using SPSS, highlighting the critical need for targeted recruitment and rural-
based medical education initiatives.
2.2.3 Availability of Medical Equipment and Essential Drugs
More than two billion people worldwide lack access to essential medications, with rural and
underserved areas being the most severely affected, according to a comprehensive report by
the World Health Organization (WHO, Essential medicines and health products information
portal: Access to medicines, 2017) on essential medications and equipment. The WHO used
Health Access Indicators from 76 different countries, utilizing secondary data analysis. Using
comparative statistical analysis, the report highlighted the need to enhance supply chain
tracking, storage facilities, and procurement systems, particularly in developing nations.
(Asare, 2020) conducted a cross-sectional quantitative study in Ghana, examining the
accessibility of diagnostic tools and tracer medications in rural facilities. They collected data
using WHO Service Availability and Readiness Assessment (SARA) tools and audited 120 public
health centers using random sampling. Less than 40% of facilities had a working oxygen supply,
blood pressure monitor, or thermometer, according to the results.
More than 30% of rural health facilities in Kenya lack basic supplies like blood pressure
monitors, delivery kits, and refrigerators for storing vaccines, according to the Ministry of
Health's (MOH, 2018)Service Availability and Readiness Mapping (SARAM). Stratified sampling
of more than 3,000 healthcare facilities was employed in this nationwide survey, which utilized
WHO SARA tools. Infrastructure indicators and readiness scores were used to analyze the data.
A qualitative study examining the challenges faced by the pharmaceutical supply chain in rural
Kenya was conducted by (Owino, 2020). The study highlighted inefficiencies in procurement and

11
inadequate coordination between counties and national medical stores, as determined through
document review and key informant interviews with pharmacists and facility managers. The
transcripts were examined using content analysis.
(Kahiga, 2021) Evaluated the sufficiency of the equipment in Taita Taveta County's sub-county
hospitals. They examined stock records and conducted on-site equipment audits in seven
hospitals using a descriptive and facility-based survey to analyze the data. According to the
study, maternal and emergency care services were seriously jeopardized because over half of
the facilities lacked oxygen cylinders, suction machines, or working delivery beds.
2.2.4 Availability of power/electricity
(Adair-Rohani, 2013) Conducted a global study evaluating energy access in healthcare facilities
in South Asia and sub-Saharan Africa. Data from 11 different countries' Demographic and Health
Surveys (DHS) and Service Provision Assessments (SPA) were used in the study at the facility
level. Descriptive and regression analyses were used to evaluate the connection between
service availability and electricity access. The findings indicated that facilities with dependable
electricity had twice the likelihood of providing emergency services and safe childbirth.
Using a quasi-experimental design, (Aklin, 2017) Examined the impact of electrification on rural
health clinics in Nigeria. Before and after solar installations, 284 healthcare facilities underwent
a difference-in-differences (DiD) analysis by the researchers. Interviews, service records, and
baseline and end-line surveys were used to gather data. According to the results, electrified
clinics saw a 30% increase in deliveries at night and a decrease in neonatal fatalities.
Only 62% of rural health facilities in Kenya had access to dependable electricity, according to the
Ministry of Health. (MOH, 2018) SARAM report: The percentage was lower in counties like Taita
Taveta. The study included a stratified sample of public and private health facilities nationwide,
utilizing the WHO Service Availability and Readiness Assessment (SARA) tools. Energy access
indicator cross-tabulation and readiness scoring were used to analyze the data.
(Kiplagat, 2019) Conducted a local study that specifically examined how electricity access
affected the dependability of the cold chain in rural Kenyan health centers. Facility audits and
structured interviews with facility managers were used to gather data from 50 facilities as part
of a quantitative observational study. More than 40% of rural clinics lacked working refrigerators
because of inconsistent power or no electricity at all, according to the study's descriptive
statistics.
In a descriptive facility-based assessment conducted in Taita Taveta County, (Kahiga,
2021)identified the availability of electricity as a critical infrastructure variable. They discovered
that a faulty power supply was causing frequent disruptions in maternity services and
interfering with diagnostic testing, as indicated by facility checklists and maintenance records.
SPSS analysis of the data revealed that establishments with reliable electricity had a higher
likelihood of offering cold storage and 24-hour services.

12
CRITICAL ANALYSIS OF EMPIRICAL STUDIES AND RESEARCH GAP
Access to quality health care services is a critical need for all human beings a health nation is a
wealth nation Mugo M.G(2012) clearly shows how socioeconomic status of people directly
influence access to health care services. Taita-Taveta county been one of the ASAL area in
Kenya, the terrain /geographical location exemplifies the many challenges it’s faces in terms of
effective health care access. Poor accessibility directly undermines the quality of health care
service delivery as; long distance and poor road networks hinder most people especially the
elderly and children access. Gizaw, et al (2022) compile key strategies from the international
experiences to improve access to primary healthcare (PHC) services in rural communities.
Though the strategies suggested by Gizaw et al (2022) may address the access challenge facing
the people of Wundanyi the ball in contention is will the county government finance and come
up with policy that will help to ensure effective access to healthcare service.

According to Kahiga, Health workforce gaps in sub-county hospitals: A study of staffing

adequacy in Taita Taveta, 2021 its evident that the ratio of medic to patient is below the
national target these leads to high workloads, burnout and high turnover rate in the county.it
was also noted that most medics in Taita-Taveta county are employed in towns such as Voi while
the remote areas like Wundanyi are left with scarce staff which not specialist. These leads to
poor service delivery due to burnout, error in diagnosis and in the long run the public lack of
trust and satisfaction in the health care delivery.

Inadequate medical supplies and dilapidated facilities undermines quality health care service
delivery. According to a comprehensive report by the World Health Organization (WHO,
Essential medicines and health products information portal: Access to medicines, 2017). Lack of
medical equipment and resources results to poor diagnostic and treatment. Most of health
centers in rural areas lack basic equipment like thermometer, painkillers, ambulance, running
water, power, reagents and testing equipment these undermines service delivery these makes
most patient to rely on home remedies. There is need for the county government to leverage on
technology and infrastructure to monitor medical supplies, real-time data capturing and easy
coordination for quality and efficiency in health care service delivery.
Only 62% of rural health facilities in Kenya had access to dependable electricity, according to the
Ministry of Health (MOH, 2018) SARAM report. Most researchers focused on electricity as the
power source for health care facilities there is need for county government to invest in
sustainable clean energy such as solar power.
According to Donabedian's model, Moore et al (2015) to achieve quality healthcare delivery
there is need for improvement in terms of structures and health processes in order to achieve
positive patient /customer satisfaction. In our study its evident there is need for government
(policy makers) both national and county to work on improving the health care structures
processes and systems to achieve effective quality service delivery.

13
2.3.1 RESEARCH GAPS
Though most rural areas face almost similar challenges Wundanyi in Taita Taveta county faces its
unique challenges. some of the key research gaps identified when well addressed can improve
efficiency in health care service. Research on internet connectivity its effectiveness in
addressing infrastructure limitation and service delivery in Taita-Taveta remote areas. More
research on impact of devolution on service delivery and critical bottlenecks that undermines
efficiency and quality health care access.
Strategies to increase staff retention and morale, according to Mutinda, et al (2019) examined
the factors that influence the retention of medical professionals in rural Kenya. There is need to
research on the specific needs of Taita Taveta staff challenges for better outcome. Action
research focused on awareness and low uptake of financial risk protection schemes such as SHA
and other insurance policy.
By addressing the research gaps the it will enable the county government to come up with
specific intervention that will address efficiency, quality and effective service delivery systems.
Beyond coming up with policy frameworks and implementation plans they should design a
monitoring and evaluation system for checks and balance.

CONCEPTUAL FRAMEWORK
This section elaborates the degree to which improved health care systems influence the health
care service delivery outcome. According to Donabedian's health care quality model Moore, et
al (2015), improvements in the structure of care should lead to improvements in clinical
processes that should in turn improve patient outcome. Improved health care systems result to
access, quality and public trust and satisfaction. The health systems as suggested by WHO is the
core or foundation the directly affects access, quality and customer satisfaction

TRANSPORT AND ACCESIBILITY

AVAILABILITY OF MEDICS AND

Health care
SPECIALISTS
delivery (access,
quality,
DRUGS AND EQUIPMENT satisfaction)
AVAILABILITY

14
 POWER/ELECTRICITY
AVAILABILITY

The health systems indicate the workforce, leadership & governance, finance, information
systems, service delivery, medical products and equipment. All these are the building blocks of
health system according World Health Organizations (WHO). The access factor entails that the
health system should be available, affordable, acceptable and within reach to the public. The
quality aspect the service delivered should follow the stipulated guidelines, low turnaround
time and standard equipment. Customer satisfaction is very crucial to any system as it build
trust and increase the utilization of the system. when health systems interrelate harmonious
with the system processes effectiveness in healthcare delivery will be achieved. As Mugo M.G
(2012) said a health nation equals to a wealth nation.

CHAPTER 3: RESEARCH METHODOLOGY

3.0 INTRODUCTION
This section describes the methodology used in this study, such as research design, where it will
be undertaken, sampling methods, data collection tools, data analysis methods, and ethical
issues. This study was conducted in a rural Taita Taveta County, Kenya, particularly the
Wundanyi Sub-County. The case represents a mixed-methods study focused on qualitative
preponderance to implement a detailed and specific perception regarding healthcare delivery
issues in Kenya's rural environments. Per (Creswell J. a., 2018)it enabled the discussion of
diverse community knowledge and the nationalization of service access measures consistent
with the suggestions of the authors who consider the importance of qualitative research in
practice.
3.2 Research Design
The research has adopted a special design by utilizing a qualitative case study design to address
the question of the effectiveness of the health delivery systems in Wundanyi. This particular
design has been chosen and aims to study complex social phenomena in practical conditions,
allowing contextually rich information on decentralization, labor shortage, and infrastructural
limitations to be derived. (Creswell J. W., 2014) remark that case study research is best suited
when exploring the bounded systems in depth, especially when the boundaries that distinguish
the phenomenon and its context are ill-defined.
The study used descriptive research design. The design was used because the objective of the
study was to collect data on detailed designated phenomena with desire to answer our case of
effectiveness of health delivery in rural areas, specifically Wundanyi subcounty in Taita-Taveta

15
county. According to (Kothari, 2004), descriptive research design is used appropriately for
studies that seek to identify and explain existing conditions or relationships without
manipulation of any variable.

Table 1: Core Elements of the Research Methodology

Component Details
Design Case study Case study mixed-methods
Location: Wundanyi Taita Taveta, Kenya
Population Adults’ public healthcare users
Sampling Cluster, convenience
Sample Size 50 (25 from Werugha 25 from
Mwanda)
Data Tools Questionnaires
Analysis Descriptive stats thematic analysis
Approach Pragmatism triangulation
Table 1: Core Elements of the Research Methodology
3.3 Study Area
The research was carried out at the Wundanyi sub-county, which is classified as a semi-arid
region found on the Kenyan coast in Taita Taveta County. The selection of this area was strategic
since it represents the rural setting and the practicality of health delivery issues in such a real
context. KNBS (2019) argues that the availability of basic amenities such as healthcare in the
remote region is significantly limited. The study's relevance is that its results can be relied on to
formulate broader health policies, particularly the rural ones. This can be applicable at the
national level.
3.4 Target Population
Target population is the entire group of individuals in which a researcher intends to study and
where the sample is drawn from (Mugenda, 2003). Researchers were interested in a population
of 250 adults living in Wundanyi and with any connection to the public health facilities in the
past 12 months
3.5 Sampling Technique and Sample Size
the sample size used was determined using (Yamane, 1968) simplified formula for calculating
sample size.
It is the process of selecting a number of individuals or objects from a population such that the
selected group contains elements represented. The study adopted a random sampling
technique and used Yaro Yamane’s 1968 formula:
N
n= 2
1+ N ( e )

16
Where; n = sample size, N = target Population, and e 2= probability error (derived from the
confidence interval).
The target population (N) was 250, whereas the study settled for 90% confidence interval (CI)
which means the probability error allowed was, 10% (0.1)
Therefore, the calculation for the sample size;
250
n= 2
1+250 (0.1)
n=50
3.6 Data Collection Methods
Data collection is a process of collecting data from respondents or various sources so as to
address research questions and objectives. (Creswell J. W., 2014) The researchers used an online
questionnaire to collect the data from the respondents. An online questionnaire was the most
appropriate method for data collection as it provided the requisite information being sought by
the researchers conveniently.
3.7 Data Analysis
According to (Mugenda, 2003) data analysis involved organizing, interpreting and drawing
recommendations and conclusion from collected data in order to make it meaning and sole a
specific research problem. In this study primary data collected from the field was code analyzed
using SPSS and EXCEL, Quantitative data obtained was cleaned to eliminate incomplete and
irrelevant responses. All responses were coded into SPSS and analyzed quantitatively using
descriptive statistics. The analyzed data was presented in form of charts, graphs and tables.
3.8 Ethical consideration
Ethical considerations were mainly factored on matters confidentiality, informed consent and
voluntary participation. Voluntary participation was informed by filling an informed consent
before filling the questionnaire. All respondents were assured of confidentiality and that this
research was soled academic purposes only and not for any commercial gain.

17
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APPENDIX A: INTRODUCTION LETTER

20
APPENDIX B: QUESTIONNAIRE

21