Level and determinants of county health system technical efficiency in Kenya: two stage data envelopment analysis

et al. 2022

BMC Health Serv Res

Self Cite

Background Human resources for health consume a substantial share of healthcare resources and determine the efficiency and overall performance of health systems. Under Kenya’s devolved governance, human resources for health are managed by county governments. The aim of this study was to examine how the management of human resources for health influences the efficiency of county health systems in Kenya. Methods We conducted a case study using a mixed methods approach in two purposively selected counties in Kenya. We collected data through in-depth interviews (n = 46) with national and county level HRH stakeholders, and document and secondary data reviews. We analyzed qualitative data using a thematic approach, and quantitative data using descriptive analysis. Results Human resources for health in the selected counties was inadequately financed and there were an insufficient number of health workers, which compromised the input mix of the health system. The scarcity of medical specialists led to inappropriate task shifting where nonspecialized staff took on the roles of specialists with potential undesired impacts on quality of care and health outcomes. The maldistribution of staff in favor of higher-level facilities led to unnecessary referrals to higher level (referral) hospitals and compromised quality of primary healthcare. Delayed salaries, non-harmonized contractual terms and incentives reduced the motivation of health workers. All of these effects are likely to have negative effects on health system efficiency. Conclusions Human resources for health management in counties in Kenya could be reformed with likely positive implications for county health system efficiency by increasing the level of funding, resolving funding flow challenges to address the delay of salaries, addressing skill mix challenges, prioritizing the allocation of health workers to lower-level facilities, harmonizing the contractual terms and incentives of health workers, and strengthening monitoring and supervision.

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

BMC Health Serv Res

Self Cite

“…We purposively selected four counties using the level of health system technical efficiency reported in phase two of the broader study 17 as a key selection criterion (Table 1). We then took into consideration other county characteristics that were identified by the quantitative efficiency analysis as determinants of efficiency.…”

Section: Methodsmentioning

confidence: 99%

“…In the first phase of the study, a systematic literature review 13 and stakeholder engagement 14 were conducted that reported PFM processes as key determinants of health system efficiency globally and at the county level in Kenya, respectively. In the second phase, a quantitative assessment of county level health system efficiency and its determinants identified PFM as one of the key determinants of county level efficiency in Kenya 15 . In this third phase of the study, we explore in-depth how the factors identified in previous study phases interact with county health system efficiency.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

Preprint

Self Cite

IntroductionPublic Finance Management (PFM) processes guide the translation of government resources to services and determine health system efficiency. PFM processes are implemented within the budget cycle which entails the formulation, execution, and evaluation of government budgets. We examined how the budget formulation structure and processes influence health system efficiency at the county level in Kenya.MethodsWe conducted a mixed methods case study using counties classified as relatively efficient (n=2) and relatively inefficient (n=2) as our cases. We collected qualitative data through document reviews, and in-depth interviews (n=70). 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.ResultsBudget ceilings were historically allocated, insufficient, late, or not availed at all. This led to development of budgets that were unresponsive to health system needs. Counties developed both programme-based and line budgets with line budgets as the functional budgets. Line budgets limited accountability and flexibility to reallocate resources. County health funds were fragmented resulting in duplications and wastage. Limited stakeholder participation compromised priority setting and social accountability. Priority setting that was not evidence-informed limited efficiency. Finally, budget changes at the budget approval process compromised alignment of plans to budgets.ConclusionThis study has highlighted six aspects of the budget formulation process in Kenyan counties that ought to be strengthened to enhance health system efficiency: budget ceilings, budget structure, participatory budget formulation, pooling of health funds, priority setting processes and the budget approval process.HighlightsLate and Insufficient budget ceilings lead to development of poorly formulated budgetsPoorly developed and unused programme-based budgets limit health system performanceFragmented health system funding results in duplication and wastageLimited stakeholder involvement compromised priority setting and accountability

“…We selected four cases - counties - using the level of technical efficiency reported in phase two of the Kenya Efficiency Study (Barasa et al ., 2021). We then took into consideration other county characteristics that were identified by the quantitative efficiency analysis as determinants of efficiency.…”

Section: Methodsmentioning

confidence: 99%

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

et al. 2022

Preprint

Self Cite

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.