Examining the Influence of the Budget Execution Processes on the Efficiency of County Health Systems in Kenya

Abstract

Public Financial Management (PFM) processes are a driver of health system efficiency. The budget execution process is the stage in the PFM cycle where health system inputs are translated into outputs and outcomes. This study examined how the budget execution process influenced the efficiency 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) in a related quantitative analysis as our cases. 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 improved provider autonomy.

Management of human resources for health: implications for health systems efficiency in Kenya

“…Second, counties should review and seek to resolve funding flow challenges that contribute to delays of salary payments to health workers. This problem is partly a broader public finance management (PFM) challenge characterized by delays in disbursement of funds to counties and from county treasuries to county departments of health and will hence require the strengthening of PFM implementation processes [53]. However, at the county level, it could also be resolved prioritizing the payment of health worker salaries before making other payments.…”

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

“…At the county level, control over resources is concentrated at the county treasury, with other departments, including the county department of health and units under it, such as health facilities having limited power and control over resources. 25 26 Given that public health facilities are one of the key sources of locally generated revenues at the county level, county-level actors are reluctant to relinquish control over these resources to public health facilities ( figure 1 ). County leaders are keen to consolidate their power and retaining control over resources and decision making is one way to achieve this.…”

“… 29 These capacity challenges have manifested in suboptimal budget formulation, execution and monitoring challenges that have affected health facility autonomy ( figure 1 ). 25 26 Capacity challenges as impediments to de facto autonomy have been documented elsewhere. 5 6 …”

“…With regard to budget formulation, we found that county health department budget ceilings are not always transparent and hence not communicated to public health facilities ( figure 1 ). 25 Without visibility over the resources that are allocated to them, public health facilities found it difficult to plan and budget and were hence disenfranchised from the opportunity to plan for and allocate resources. While the inadequate transparency of budget ceilings is partly attributed to process inadequacies, it is also a manifestation of political interests by county level actors that are keen to retain control over resource allocation and expenditure decisions.…”

“…While the inadequate transparency of budget ceilings is partly attributed to process inadequacies, it is also a manifestation of political interests by county level actors that are keen to retain control over resource allocation and expenditure decisions. 25 The inadequate visibility over resources available to health facilities was also caused by the off-budget support that counties and health facilities got from donors. 25 Public health facility’s ability to adequately plan, prioritise, and spend is compromised by the practice whereby donors do not reveal their funding support to counties and health facilities, and go ahead to implement supported activities outside of government PFM systems and planning and budgeting processes.…”