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

Abstract

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.

Reconciling devolution with health financing and public financial management: challenges and policy options for the health sector

“…Although this problem is not restricted to devolved settings, subnational governments may have a strong interest in limiting facility autonomy to maximise their revenues. 18 …”

Childhood mortality and associated factors in Migori County, Kenya: evidence from a cross-sectional survey

“…Regional U5M rates in Kenya in 2014 ranged from 42 to 82 per 1000 live births 6. This underlines the need for local data to inform ongoing programmatic efforts, especially in decentralised health systems like Kenya where allocative health decisions are made at the county level 8…”

“…6 This underlines the need for local data to inform ongoing programmatic efforts, especially in decentralised health systems like Kenya where allocative health decisions are made at the county level. 8 Migori County is situated in western Kenya in the former Nyanza province and has a population of approximately 1.1 million. 9 The economy primarily relies on subsistence farming with fishing prevalent in areas that border Lake Victoria.…”

Public Primary Health Facilities Autonomy: Findings from Tanzania Star Rating Assessment

“…This is a reform approach that involves reducing direct government control over public hospitals and increasing their exposure to market and market like incentives [1,2]. The financing of public health facilities influences their performance with degree of financial autonomy being a key feature that defines health facility financing [3]. Financial autonomy refers to the level of control and influence that health facility managers have, to mobilize, allocate and spend financial resources [4].…”

“…While decentralization is often expected to enhance financial autonomy at the local levels, evidence has shown that this is not always the case [4]. For instance, in Kenya decentralization resulted in a counterintuitive recentralization of autonomy over financial management from the public health facility level to the local government level and therefore, understanding the factors that influence public health facility financial autonomy is pertinent to developing strategies to addressing prevailing challenges [3].…”