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

1. Longitudinal research tracking the financing
of peripheral public health care facilities in
Kenya
P4P – Evelyn Waweru Nov 2015

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Experiences with HSSF implementation

13. 0.9% of total ‘on-budget’ health sector budget

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. ▪ 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Acknowledgements
• Supervisors: Drs Sassy
Molyneux, Catherine
Goodman
• Co-investigators:
Benjamin Tsofa, Mary
Nyikuri, Jacinta Nzinga,
Edwine Barasa, Jane
Chuma, Anisa Omar,
Timothy Malingi