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

Nyawira, Lizah; Mbau, Rahab; Jemutai, Julie; Musiega, Anita; Hanson, Kara; Molyneux, Sassy; Normand, Charles; Tsofa, Benjamin; Maina, Isabela; Mulwa, Andrew; Barasa, Edwine

doi:10.1371/journal.pgph.0000077

Cited by 11 publications

(15 citation statements)

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“…Quantitative approaches were used to measure the level and determinants of efficiency. Qualitative approaches were used to examine study participants’ perceptions about the objectives of the health system [ 41 , 45 ] and existence and nature of health system inefficiency and its determinants [ 41 , 45 – 48 ]. Beyond identification, qualitative approaches provided explanations of the relationship between identified determinants and health system efficiency [ 36 , 48 , 49 ].…”

Section: Resultsmentioning

confidence: 99%

“…Public finance management arrangements also influenced health system efficiency. Enhanced capacity to execute budgets, flow of funds directly to providers, timeliness of funds disbursements to local authorities and health facilities, the flexibility of budgets, and the autonomy of local authorities and health facilities over resources enhanced efficiency [ 45 , 47 , 48 ].…”

Section: Resultsmentioning

confidence: 99%

“…In China and El Salvador, the introduction medicines regulations that strengthened price regulation, generic prescribing, and the enforcement of national essential drugs lists improved health system efficiency [ 53 ]. Improved coordination in the health sector, including the coordination of donor initiatives, was also associated with improved health system efficiency [ 45 , 53 ]. The Democratic Republic of Congo and Zambia realised improvement in health system efficiency by aligning and coordinating donor support with health sector priorities, and coordinating health sector planning, budgeting and resource allocation to reduce waste and duplication [ 36 , 53 ].…”

Section: Resultsmentioning

confidence: 99%

“…Effective performance monitoring and accountability was found to improve health system efficiency in Canada [ 46 ]. Leadership and management practices and capacity were also thought to be a determinant of health system efficiency [ 45 , 46 , 53 ]. An assessment of the technical efficiency of 27 Latin American and Caribbean countries found a positive association between governance quality and system technical efficiency [ 26 ].…”

Section: Resultsmentioning

confidence: 99%

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Analysing the Efficiency of Health Systems: A Systematic Review of the Literature

Mbau

Musiega

Nyawira

et al. 2022

Appl Health Econ Health Policy

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Background Efficiency refers the use of resources in ways that optimise desired outcomes. Health system efficiency is a priority concern for policy makers globally as countries aim to achieve universal health coverage, and face the additional challenge of an aging population. Efficiency analysis in the health sector has typically focused on the efficiency of healthcare facilities (hospitals, primary healthcare facilities), with few studies focusing on system level (national or sub-national) efficiency. We carried out a thematic review of literature that assessed the efficiency of health systems at the national and sub-national level. Methods We conducted a systematic search of PubMed and Google scholar between 2000 and 2021 and a manual search of relevant papers selected from their reference lists. A total of 131 papers were included. We analysed and synthesised evidence from the selected papers using a thematic approach (selecting, sorting, coding and charting collected data according to identified key issues and themes). Findings There were more publications from high-and upper middle-income countries (53%) than from low-income and lower middle-income countries. There were also more publications focusing on national level (60%) compared to sub-national health systems' efficiency. Only 6% of studies used either qualitative methods or mixed methods while 94% used quantitative approaches. Data envelopment analysis, a non-parametric method, was the most common methodological approach used, followed by stochastic frontier analysis, a parametric method. A range of regression methods were used to identify the determinants of health system efficiency. While studies used a range of inputs, these generally considered the building blocks of health systems, health risk factors, and social determinants of health. Outputs used in efficiency analysis could be classified as either intermediate health service outputs (e.g., number of health facility visits), single health outcomes (e.g., infant mortality rate) or composite indices of either intermediate outputs of health outcomes (e.g., Health Adjusted Life Expectancy). Factors that were found to affect health system efficiency include demographic and socio-economic characteristics of the population, macro-economic characteristics of the national and sub-national regions, population health and wellbeing, the governance and political characteristics of these regions, and health system characteristics. Conclusion This review highlights the limited evidence on health system efficiency, especially in low-and middle-income countries. It also reveals the dearth of efficiency studies that use mixed methods approaches by incorporating qualitative inquiry. The review offers insights on the drivers of the efficiency of national and sub-national health systems, and highlights potential targets for reforms to improve health system efficiency.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 2 more Smart Citations

Analysing the Efficiency of Health Systems: A Systematic Review of the Literature

Mbau

Musiega

Nyawira

et al. 2022

Appl Health Econ Health Policy

Self Cite

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show abstract

“…This control could also be used inappropriately, and county level political interests have been shown to influence decisions with negative implications for health system performance. 13 27 It is likely that such political interest in control over resources manifests in overt resistance by some counties to give public health facilities autonomy, or covert resistance, camouflaged in strategic misinterpretation of PFM laws. Similar findings have been reported in Malawi where politicians resisted hospital autonomy reforms on the basis that it would lead to loss of power and control over resources.…”

Section: Determinants Of Public Health Facility Financial Autonomymentioning

confidence: 99%

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

et al. 2022

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The financing of public health facilities influences their performance. A key feature that defines health facility financing is the degree of financial autonomy. Understanding the factors that influence public health facility financial autonomy is pertinent to developing strategies to addressing challenges that arise from constrained autonomy. In this paper, we apply a complexity lens to draw on a body of research that we have conducted in Kenya over the past decade, from the onset of devolution reforms, to unpack the determinants of public health facility financial autonomy in a context of decentralisation and provide suggestions for pertinent considerations when designing interventions to address financial autonomy challenges. We find that the factors that affect public health facility autonomy are not only structural, but also procedural, and political and interact in complex ways. These factors include; the public finance management (PFM) laws, sense-making by actors in the health system, political interests in control over resources, subnational level PFM capacity, PFM implementation bottlenecks and broader operational autonomy. Drawing from this analysis, we recommend that efforts at resolving public health facility financial autonomy include: PFM capacity development for subnational levels of government in decentralised settings, the use of a political lens that recognises interests and seeks to align incentives in engagement and solution finding for health facility financial autonomy, the audit of PFM processes to establish and resolve implementation bottlenecks that impinge on public health facility autonomy, and the resolution of operational autonomy to as a facilitator of financial autonomy.

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Examining the influence of budget execution processes on the efficiency of county health systems in Kenya

Musiega

Tsofa

Nyawira

et al. 2022

Health Policy and Planning

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Public Financial Management (PFM) processes are a driver of health system efficiency. PFM happens within the budget cycle which entails budget formulation, execution and accountability. At the budget execution phase, budgets are implemented by spending as planned to generate a desired output or outcome. Understanding how the budget execution processes influence the use of inputs, and the outcomes that result is important for maximizing efficiency. This study sought to explain how the budget execution processes influence the efficiency of health systems, an area that is understudied, using a case study of county health systems in Kenya. We conducted a concurrent mixed methods case study using counties classified as relatively efficient (n=2) and relatively inefficient (n=2). We developed a conceptual framework from a literature review to guide the development of tools and analysis. We collected qualitative data through document reviews, and in-depth interviews (n=70) with actors from health and finance sectors at the national and county level. We collected quantitative data from secondary sources, including budgets and budget reports. We analyzed qualitative data using the thematic approach and carried out descriptive analyses on quantitative data. The budget execution processes within counties in Kenya were characterized by poor budget credibility, cash disbursement delays, limited provider autonomy, and poor procurement practices. These challenges were linked to an inappropriate input mix that compromised the capacity of county health systems to deliver healthcare services, misalignment between county health needs and the use of resources, reduced staff motivation and productivity, procurement inefficiencies, and reduced county accountability for finances and performance. The efficiency of county health systems in Kenya can be enhanced by improving budget credibility, cash disbursement processes, procurement processes, and provider autonomy.

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

Cited by 11 publications

References 35 publications

Analysing the Efficiency of Health Systems: A Systematic Review of the Literature

Analysing the Efficiency of Health Systems: A Systematic Review of the Literature

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

Examining the influence of budget execution processes on the efficiency of county health systems in Kenya

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