Examining health facility financing in Kenya in the context of devolution

Background

How health facilities are financed affects their performance and health system goals. We examined how health facilities in the public sector are financed in Kenya, within the context of a devolved health system.

Methods

We carried out a cross-sectional study in five purposely selected counties in Kenya, using a mixed methods approach. We collected data using document reviews and in-depth interviews (no = 20). In each county, we interviewed county department of health managers and health facility managers from two and one purposely selected public hospitals and health center respectively. We analyzed qualitive data using thematic analysis and conducted descriptive analysis of quantitative data.

Results

Planning and budgeting: Planning and budgeting processes by hospitals and health centers were not standardized across counties. Budgets were not transparent and credible, but rather were regarded as “wish lists” since they did not translate to actual resources. Sources of funds: Public hospitals relied on user fees, while health centers relied on donor funds as their main sources of funding. Funding flows: Hospitals in four of the five study counties had no financial autonomy. Health centers in all study counties had financial autonomy. Flow of funds to hospitals and health centers in all study counties was characterized by unpredictability of amounts and timing. Health facility expenditure: Staff salaries accounted for over 80% of health facility expenditure. This crowded out other expenditure and led to frequent stock outs of essential health commodities.

Conclusion

The national and county government should consider improving health facility financing in Kenya by 1) standardizing budgeting and planning processes, 2) transitioning public facility financing away from a reliance on user fees and donor funding 3) reforming public finance management laws and carry out political engagement to facilitate direct facility financing and financial autonomy of public hospitals, and 4) assess health facility resource needs to guide appropriate levels resource allocation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07123-7.

Using process net-map to analyse governance challenges: A case study of livestock vaccination campaigns in Zambia

The outbreak of livestock diseases in Sub-Saharan African countries is the most critical challenge affecting the development potential of the livestock sector. Vaccination campaigns are one of the most important strategies to deal with this challenge. However, such campaigns are difficult to implement due to major governance challenges, such as delays in the procurement of vaccines and the disbursement of funds. This paper presents an in-depth analysis of these governance challenges, based on a case study of a Livestock Development Animal Health Project in Zambia. The goal was to examine in detail why these problems occur and how they are linked to the implementation procedure. A novel qualitative research tool called Process Net-Map, which is a visual participatory mapping technique was applied. The tool made it possible to develop an understanding of the exact implementation mechanism and to identify the different actors involved, including government officials, private sector companies, and farmers. The study revealed that the complex design of the procurement procedure, the limited capacity of the procuring entity, and a lack of urgency among the actors involved, resulted in the procurement delays. The findings also indicate that the delay in the release of funds arises because of a diversion of funds. Some strategies to improve the efficiency of the procurement process were identified, such as increasing the sense of urgency, building staff capacity, using e-procurement and entering into framework contracts with suppliers. Building sustainable financial capacity in the overall management of public funds seems essential to deal with the challenge of fund diversion. Use of Citizen Report Cards and lobbying political decision markers are some of the mechanisms that farmers can employ to increase their capacity to hold the animal health service providers accountable and demand better services. The problems identified are not only relevant for vaccination programs but are general implementation challenges encountered in developmental programs that involve the distribution of publicly procured inputs.