Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Longitudinal research tracking the financing
of peripheral public health care facilities in
Kenya
P4P – Evelyn Waweru Nov ...
Outline
▪ Background: Kenyan health sector reforms
▪ Research methods (HSSF): pilot – baseline – interim
– post devolution...
Health Sector Services Fund
▪ An innovative GOK scheme to:
- disburse funds directly to peripheral facilities
- empower lo...
District
Focus
DEVOLUTION
(2013)
KHSSP &
KEPH
(1999*)
Updated financial
guidelines
Gazette HFMCs (2009)
Kenya Health Polic...
2005 Coast Pilot: Methods
▪ Post-hoc assessment, conducted 2 to 3 years after
the scheme was introduced.
▪ It was not poss...
Community
Engagement and
Accountability
Fees and
Exemptions
Health Worker
Motivation
Facility Level
Expenditure
Increased ...
Coast Pilot: Key findings
• Positive findings: HFMCs active and met regularly, funds
transferred and used appropriately an...
Baseline survey (2010)
KWTRP commissioned by MOPHS
▪ Cross sectional survey of 248
peripheral facilities in 8
provinces
Me...
Baseline: Key findings
▪ Most facilities were ready to
receive HSSF:
- Bank account
- Functioning HFMC
- Some training – m...
2012 HSSF interim study
Aim to conduct an “open box” process evaluation of early
experiences of HSSF, documenting how it w...
Methods (HSSF interim study)
• Review of policy documents, administrative reports,
and financial data related to HSSF
• Ke...
Experiences with HSSF implementation
0.9% of total ‘on-budget’ health sector budget
▪ Disbursements started in November 2010 and by 2013 the money was being
sent to almost all DHMTs, public health centres a...
▪ Funds were reaching facilities
▪ Visible improvements in facilities
▪ More reported outreach activities
▪ Improved perce...
HSSF Implementation Challenges
Financing
▪ Delays in receiving funds: AIEs
were also fixed
▪ Inadequate level of funds
▪ L...
Unintended consequences
▪ Difficult documentation
with the reporting
process still centralised
▪ Difficulties in accessing...
Now? Re-organisation of the Kenyan
health system
• Devolution: 47 new semi-
autonomous counties (control
decisions)
• User...
Financing of peripheral public health care
facilities in Kenya: 

similarities and differences across counties in
strategi...
Conceptual framework : How HSSF is to function in a devolved health
system context
• 1.
• Use of Funds
• 2.
• Access rules...
Study site selection
Kilifi County
National Level KIs
Vihiga County
Sub
County1
Kajiado County
Sub
County3
Sub
County 2
Su...
Data collection methods
National
• MOH, National treasury, the HSSF Secretariat, CRA,
Donors (World Bank, DANIDA and WHO)
...
Limitations
• Primarily qualitative: need for balanced mixed
methods - baseline costing requirements to guide
resource all...
Opportunities and future considerations
• Use of mixed methods, process evaluation,
economic evaluation?
• Theory driven d...
Acknowledgements
• Supervisors: Drs Sassy
Molyneux, Catherine
Goodman
• Co-investigators:
Benjamin Tsofa, Mary
Nyikuri, Ja...
Upcoming SlideShare
Loading in …5
×

Longitudinal research tracking the financing of peripheral public health care facilities in Kenya - Evelyn Waweru

This presentation was given at the pay-for-performance workshop in Tanzania, November 2015.

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all
  • Be the first to comment

  • Be the first to like this

Longitudinal research tracking the financing of peripheral public health care facilities in Kenya - Evelyn Waweru

  1. 1. Longitudinal research tracking the financing of peripheral public health care facilities in Kenya P4P – Evelyn Waweru Nov 2015
  2. 2. Outline ▪ Background: Kenyan health sector reforms ▪ Research methods (HSSF): pilot – baseline – interim – post devolution ▪ Challenges and opportunities in using the above methods ▪ Current proposal and way forward NB: Peripheral health facilities = public health centres and dispensaries
  3. 3. Health Sector Services Fund ▪ An innovative GOK scheme to: - disburse funds directly to peripheral facilities - empower local communities through Health Facility Management Committees (HFMCs) • Overall goal: – generate sufficient resources for providing curative, preventive and promotive services – Reduce user fees paid – account for the resources in an efficient and transparent manner
  4. 4. District Focus DEVOLUTION (2013) KHSSP & KEPH (1999*) Updated financial guidelines Gazette HFMCs (2009) Kenya Health Policy Framework (1994*) DHC/HFMCs 1975 1980 1985 1990 User Fees Cost sharing (2004) Communit y Strategy FREE Context: Global Health Debates: UHC, decentralisation and community participation 2010 Baseline survey 2012 Interim 2015 Proposal 2005 Pilot Empirical research evaluating HSSF implementation DFF Coast HSSF Kenya
  5. 5. 2005 Coast Pilot: Methods ▪ Post-hoc assessment, conducted 2 to 3 years after the scheme was introduced. ▪ It was not possible to assess the quantitative impact on key indicators, such as utilization and fees charged, - No baseline data had been collected prior to implementation, - Health Management Information System (HMIS) data were neither sufficiently complete nor reliable. ▪ Focused our quantitative analysis on intermediate/process outcomes that could be easily linked to the direct funding intervention, and using qualitative methods to explore stakeholder opinions on impact.
  6. 6. Community Engagement and Accountability Fees and Exemptions Health Worker Motivation Facility Level Expenditure Increased Utilisation of services Approval of Facility Improved Quality of Services Setup & Implemen- tation Context: Facility type and setting, experience with managing facility level funds, other MOH, NGO and FBO activities, general political and economic developments Process Outcomes Impact Committee Functioning Training and Guidelines Facility Income Planning and Financial Management Systems Support Supervision Theory of Change: how we think HSSF should work
  7. 7. Coast Pilot: Key findings • Positive findings: HFMCs active and met regularly, funds transferred and used appropriately and accounting procedures were followed – perceived impact: small increases in the funding available for the day to day running of facilities greatly improved facility functioning and perceived quality of care • Key challenges: inadequate training and documentation, lack of awareness of HSSF among the broader community, and continued charging of user fees above the official regulations. • Building on this experience, HSSF was scaled up nationwide in public sector health centres and dispensaries.
  8. 8. Baseline survey (2010) KWTRP commissioned by MOPHS ▪ Cross sectional survey of 248 peripheral facilities in 8 provinces Methods ▪ Document reviews ▪ Interviews ▪ Questionnaires per facility (n=6) In-charge HFMC (2) Patient (3)
  9. 9. Baseline: Key findings ▪ Most facilities were ready to receive HSSF: - Bank account - Functioning HFMC - Some training – more emphasis on financial management ▪ Associations between health facility characteristics and the poverty level of the facility location - No major inequalities in inputs received with slight pro-rich indicators in elec., lab, drug availability and staff - There was need for an overall increase in inputs: ▪ User fees did not increase but there was still no adherence to cost sharing policy (10/20) Health Policy and Planning
  10. 10. 2012 HSSF interim study Aim to conduct an “open box” process evaluation of early experiences of HSSF, documenting how it works or does not work, including interactions with the broader health system, and the potential for unintended consequences
  11. 11. Methods (HSSF interim study) • Review of policy documents, administrative reports, and financial data related to HSSF • Key informant interviews with key stakeholders at national level (9) • Sampling ➢ Selection: range of SES levels, and geographic locations, discussions with DHMT (performance) • Data collection in 10 health centres in 5 districts: ➢ 22 semi-structured interviews with managers, accountants and facility in-charges ➢ 10 FGDs with committee members ➢ 99 exit survey with users (curative) ➢ facility record reviews on income and expenditure
  12. 12. Experiences with HSSF implementation
  13. 13. 0.9% of total ‘on-budget’ health sector budget
  14. 14. ▪ Disbursements started in November 2010 and by 2013 the money was being sent to almost all DHMTs, public health centres and dispensaries 
 KSH 112,000 (1,339 USD) per health centres
 KSH 27,500 (327 USD) per dispensaries
 KSH 131,500 (1,565 USD) per DHMTs
 Per Quarter
  15. 15. ▪ Funds were reaching facilities ▪ Visible improvements in facilities ▪ More reported outreach activities ▪ Improved perceived quality of care, staff motivation and patient satisfaction ▪ Active involvement of HFMCs; greater transparency and improved oversight of user fee revenues Perceived positive impacts
  16. 16. HSSF Implementation Challenges Financing ▪ Delays in receiving funds: AIEs were also fixed ▪ Inadequate level of funds ▪ Low allowances “peanuts” ▪ Different donor opinions “the lack of the involvement of the district treasury is the Achilles heel of HSSF” (National KI) Low adherence to user fee policy ▪ Only one facility reported reducing user fees ▪ User fee revenue accounted for half of facility annual income: – User fees – USD 910 – 25,455 – HSSF funds – USD 3,870 – 6,543 Supportive supervision ▪ Lack of training on financial management ▪ Lack of facilitation and systematic M&E ▪ Overworked CBAs ▪ Reluctant in-charges “Kwamad with terror” (National KI) ▪ Lack of clarity in roles and responsibilities across all levels ▪ Low community awareness of HSSF
  17. 17. Unintended consequences ▪ Difficult documentation with the reporting process still centralised ▪ Difficulties in accessing crucial user fee funds: same access rules ▪ Bypassing the district treasury  ▪ Relationship problems between key stakeholders - Diff views on how HSSF should work after devolution Recommendations ▪ Expand decision space - local levels ▪ Facilitate supportive supervision - Improvise to manage paperwork ▪ Clarify roles and responsibilities: refresher training ▪ Increase pool, buy- in / alternatives ▪ Increase inputs
  18. 18. Now? Re-organisation of the Kenyan health system • Devolution: 47 new semi- autonomous counties (control decisions) • User fee “removal” + free maternal (P. Directive) • Debate on future HSSF design o funds be controlled at county of national level? o integrated into standard government financial systems? Role of insurance? o performance related?
  19. 19. Financing of peripheral public health care facilities in Kenya: 
 similarities and differences across counties in strategies, and their implementation and perceived impact 1. To describe the range of financing approaches for peripheral facilities across Kenyan counties – allocation of HSSF funds, alternative finance mechanisms, accountability and supervision processes, and staff involved 2. To document peripheral facility income sources, levels and expenditure patterns in the period before and during devolution 3. To explore how differences in supportive supervision and accountability procedures affect facility processes
  20. 20. Conceptual framework : How HSSF is to function in a devolved health system context • 1. • Use of Funds • 2. • Access rules • 3. • Human resource • 4. • Governance / • accountability • 5. • Resource Allocation Context: Peripheral facility funding regulatory/legislative frameworks, policies and priorities of national government, international organisations, and county government Consequences for peripheral health facilities Facility income & expenditure Adherence to user fee regulations Internal & community accountability Health worker motivation   Perceived Quality of care Utilisation   5 key decision making domains: theory and practice
  21. 21. Study site selection Kilifi County National Level KIs Vihiga County Sub County1 Kajiado County Sub County3 Sub County 2 Sub County4 Sub County6 Sub County5 Sub County7 Sub County9 Sub County8 1 HC 1 Disp 1 HC 1 Disp 1 HC 1 Disp 1 HC 1 Disp 1 HC 1 Disp 1 HC 1 Disp 1 HC 1 Disp 1 HC 1 Disp 1 HC 1 Disp TOTALS National interviews: 12 or more Counties: 3 Sub-counties: 9 Health centres: 9 Dispensaries: 9 Selection of counties and sub- counties • Geographical location • SES • Interim study sites • For sub-county rural/Urban
  22. 22. Data collection methods National • MOH, National treasury, the HSSF Secretariat, CRA, Donors (World Bank, DANIDA and WHO) County • CHMT, • CBAs, county treasury • County assembly Sub- county • Sub-county health management team members (at least 4) Facility • Facility in-charge (health workers) • HFMC (Quorum of 3) • Patients (after curative care) In-depth interviews Observation Meeting minutes FGDs Document review Questionnaires In-depth interviews Document review In-depth interviews Document review In-depth interviews Document review
  23. 23. Limitations • Primarily qualitative: need for balanced mixed methods - baseline costing requirements to guide resource allocation? • Achievements of one financing intervention in the context of other mechanisms and other mechanisms • Comparative sampling • Timeliness of data analysis and write up • Influence of contextual challenges, – Unreliable drug supply, – Poor access to emergency transportation – Shortages of qualified staff – Limits in downwards accountability to users and communities. – Continuity: personnel and funding- for reflexivity
  24. 24. Opportunities and future considerations • Use of mixed methods, process evaluation, economic evaluation? • Theory driven design • How to evaluate the interactions between and influences of different mechanisms studied • Learning from challenges and opportunities • Data sharing opportunities • Your suggestions?
  25. 25. Acknowledgements • Supervisors: Drs Sassy Molyneux, Catherine Goodman • Co-investigators: Benjamin Tsofa, Mary Nyikuri, Jacinta Nzinga, Edwine Barasa, Jane Chuma, Anisa Omar, Timothy Malingi

×