Examining health facility financing in Kenya in the context of devolution

Abstract

Background How health facilities are financed affects their performance and health system goals. We examined how health facilities in the public sector are financed in Kenya, within the context of a devolved health system. Methods We carried out a cross-sectional study in five purposely selected counties in Kenya, using a mixed methods approach. We collected data using document reviews and in-depth interviews (no = 20). In each county, we interviewed county department of health managers and health facility managers from two and one purposely selected public hospitals and health center respectively. We analyzed qualitive data using thematic analysis and conducted descriptive analysis of quantitative data. Results Planning and budgeting: Planning and budgeting processes by hospitals and health centers were not standardized across counties. Budgets were not transparent and credible, but rather were regarded as “wish lists” since they did not translate to actual resources. Sources of funds: Public hospitals relied on user fees, while health centers relied on donor funds as their main sources of funding. Funding flows: Hospitals in four of the five study counties had no financial autonomy. Health centers in all study counties had financial autonomy. Flow of funds to hospitals and health centers in all study counties was characterized by unpredictability of amounts and timing. Health facility expenditure: Staff salaries accounted for over 80% of health facility expenditure. This crowded out other expenditure and led to frequent stock outs of essential health commodities. Conclusion The national and county government should consider improving health facility financing in Kenya by 1) standardizing budgeting and planning processes, 2) transitioning public facility financing away from a reliance on user fees and donor funding 3) reforming public finance management laws and carry out political engagement to facilitate direct facility financing and financial autonomy of public hospitals, and 4) assess health facility resource needs to guide appropriate levels resource allocation.

Examining health sector stakeholder perceptions on the efficiency of county health systems in Kenya

“…These included delays in disbursements of funds from the national government to county governments, and from county governments to healthcare facilities funds. Funding delays affect efficiency by compromising the planning because of the unpredictability of resource availability [31,32]. Previous studies have documented delays with funding disbursement to counties and health facilities in the Kenyan health system as a challenge [2,33].…”

The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya

“… 12 Further, some counties have reintroduced health facility financial autonomy without amending existing or developing new legislation. 12 It is also instructive that negotiations between development partners and the government led to the creation of special purpose accounts for donor conditional grants for public primary health facilities. 12 The creation of these special purpose accounts has been within the existing PFM laws and led to a situation in some counties where primary healthcare facilities have financial autonomy while public hospitals do not.…”

“… 12 It is also instructive that negotiations between development partners and the government led to the creation of special purpose accounts for donor conditional grants for public primary health facilities. 12 The creation of these special purpose accounts has been within the existing PFM laws and led to a situation in some counties where primary healthcare facilities have financial autonomy while public hospitals do not. 12 So, while the PFM laws that determine PFM structure and processes clearly have a role to play in determining public health facility financial autonomy, it is apparent that this is only part of the picture, and that other factors are at play.…”

“…The Kenyan experience has been that while the PFM laws provide for provisions for public health facilities to have financial autonomy, system actors at the county level in some counties have inappropriately (mis)interpreted the PFM laws as providing no exceptions or options for autonomy at the public health facility level. 12 Counties that allowed public health facilities to have financial autonomy without the need to develop or amend legislation correctly implemented PFM laws, while counties that developed or amended legislation and then provided health facilities with financial autonomy are likely to have innocently misinterpreted PFM legislation. However, we argue that counties that have continued to deny public health facilities financial autonomy, with or without new or amended legislation, are likely strategically misinterpreting PFM laws, driven by political interests in the control of resources.…”

Examining the Influence of the Budget Formulation Structures and Processes on the Efficiency of County Health Systems in Kenya

“…At the national level, one study documented misalignment in the planning and budgeting processes 7 . At the facility level, there was limited autonomy of health workers in the budgeting process 8 and budgets were neither transparent nor credible 9 . At the county level there was misalignment of the planning and budgeting processes 10 and there were challenges with the tools and guidelines to guide the implementation of the PBB 11 .…”