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A Critical Assessment of the Implications of Devolution on Fiscal Space for Health at County Level in Kenya
No full textSufficient public expenditure on health (PHE) is critical to the attainment of universal health coverage (UHC). Fiscal space for health is the capability of a government to assign more resources to PHE without affecting its financial and economic position. Decentralisation arrangements have implications for PHE and therefore for fiscal space for health. This thesis critically assessed the implications of decentralisation on fiscal space for health at subnational (county government) level in Kenya and its implications on the attainment of UHC.
A convergent parallel mixed methods design was used informed by a conceptual framework that guided the collection, analysis and integration of the results. Qualitative data were collected using a multiple case study approach with a focus on fiscal arrangements and changes in the government-citizen relationship. The units of analysis were 3 purposively selected counties. Data collection was through document reviews, interviews with key informants and focus group discussions. Data analysis was using a thematic analysis method. Quantitative data were from panel data regression analysis of secondary data of PHE of all 47 county governments spanning three financial years (FY 2014/15 to FY 2016/17). The integration of mixed methods arms was performed through a narrative weaving approach.
Fiscal space for health was limited across all the case study counties evidenced by unchanging levels of per capita PHE and county government health expenditure as a proportion of total county government expenditure over time. There is overlap and poor coordination in performance of functions and challenges in revenue assignments, with potentially constricting effects on fiscal space for health. PHE was also potentially discouraged by inappropriate public finance arrangements and low capacity for planning and budgeting e.g. fixed ratios on development and recurrent spending. Well designed and implemented conditional grants potentially encouraged growth in PHE but their effect was blunted by those that were poorly designed and implemented. Narrowly defined and poorly applied mechanisms for social accountability potentially discouraged PHE. Significant and contextual challenges in the application of electoral accountability were observed with unclear implications on PHE. the determinants of per capita public health expenditure at county level in Kenya are per capita total conditional grant, per capita share of equitable revenue and per capita conditional grant. From the random effects model there is the strongest evidence that a 1% change in per capita total conditional grant results in a 0.09% (p <0.001, 95% CI 0.04% – 0.14%) change on per capita public health expenditure by county governments; and that a 1% change in per capita equitable share results in a 0.68% (p<0.001, 95% CI 0.45% - 0.92%) change in per capita public health expenditure by county governments.
Decentralisation, mediated through fiscal arrangements and changes in the government-citizen relationship, has not increased fiscal space for health at decentralised level in Kenya. Better-functioning organisations and institutional arrangements that support these two mediators may expand fiscal space for health at this level. The design and operationalisation of vertical transfers and of conditional grants is critical. Strengthening of accountability mechanisms through a move to strategic social accountability may also contribute to increased fiscal space for health
The progressivity of health-care financing in Kenya
No full textBackground: Health-care financing should be equitable. In many developing countries such as Kenya, changes to health-care financing systems are being implemented as a means of providing equitable access to health care with the aim of attaining universal coverage. Vertical equity means that people of dissimilar ability to pay make dissimilar levels of contribution to the health-care financing system. Vertical equity can be analysed by measuring progressivity.<p></p>
Objectives: The aim of this study was to analyse progressivity by measuring deviations from proportionality in the relationship between sources of health-care financing and ability to pay using Kakwani indices applied to data from the Kenya Household Health Utilisation and Expenditure Survey 2007.<p></p>
Methods: Concentration indices and Kakwani indices were obtained for the sources of health-care financing: direct and indirect taxes, out of pocket (OOP) payments, private insurance contributions and contributions to the National Hospital Insurance Fund. The bootstrap method was used to analyse the sensitivity of the Kakwani index to changes in the equivalence scale or the use of an alternative measure of ability to pay.<p></p>
Results: The overall health-care financing system was regressive. Out of pocket payments were regressive with all other payments being proportional. Direct taxes, indirect taxes and private insurance premiums were sensitive to the use of income as an alternative measure of ability to pay. However, the overall finding of a regressive health-care system remained.<p></p>
Conclusion: Reforms to the Kenyan health-care financing system are required to reduce dependence on out of pocket payments. The bootstrap method can be used in determining the sensitivity of the Kakwani index to various assumptions made in the analysis. Further analyses are required to determine the equity of health-care utilization and the effect of proposed reforms on overall equity of the Kenyan health-care system
A critical analysis of purchasing arrangements in Kenya: the case of micro health insurance
No full textAbstract Background Strategic purchasing can ensure that financial resources are used in a way that optimally enhances the attainment of health system goals. A number of low- and middle-income countries, including Kenya, have experimented with micro health insurance (MHIs) as a means to purchase health services for the informal sector. This study aimed to examine the purchasing practices of MHIs in Kenya. Methods The study was guided by an analytical framework that compared purchasing practices of MHIs with the ideal actions for strategic purchasing along three pairs of principal-agent relationships (government-purchaser, purchaser-provider and citizen-purchaser). The study adopted a qualitative descriptive case study design with 2 MHIs as cases. Data were collected through document reviews (regulation, marketing materials, websites) and semi-structured interviews with key informants (n = 27). Results The regulatory framework for MHIs did not adequately support strategic purchasing practice and was exacerbated by poor coordination between health and financial sectors. The MHIs strategically contracted health providers over whom they could exercise bargaining power, sometimes at the expense of quality. There were no clear channels for beneficiaries to provide timely feedback to the purchaser. MHIs premium payments were family-based, low-cost and offered limited benefits. Coverage was based on ability to pay, which may have excluded low-income households from membership. Conclusions Adequate policy, legal and regulatory frameworks that integrate MHIs into the broader health financing system and support strategic purchasing practices are required. The state departments responsible for finance and health should form coordinating structures that ensure that MHI’s role in universal health coverage is owned across all relevant sectors, and that actors, such as regulators, perform in a coordinated manner. The frameworks should also seek to align purchasers’ relationships with providers so that clear and consistent signals are received by providers from all purchasing mechanisms present within the health system
A Critical Analysis of Purchasing Arrangements in Kenya: The Case of the National Hospital Insurance Fund
No full textBackground
Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries (LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the National Hospital Insurance Fund (NHIF) as a case study.
Methods
We applied a principal-agent relationship framework, which identifies three pairs of principal-agent relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through document reviews (statutes, policy and regulatory documents) and in-depth interviews (n = 62) with key informants including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers. Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed using a thematic framework approach.
Results
The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting, monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist, they do not always function appropriately and awareness of these channels to the beneficiaries is limited.
Conclusion
Addressing the gaps in the NHIF’s purchasing performance requires a number of approaches. Critically, there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the multiplicity of actors given Kenya’s devolved context. Relatively recent decentralisation reforms present an opportunity that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal health coverage (UHC)
Understanding factors influencing the use of clinical guidelines in low-income and middle-income settings : a scoping review
No full textKenya’s Strategic Health Purchasing Progress Matrix
No full textCountries, including Kenya, have committed to achieve Universal Health coverage (UHC) and are increasingly reforming their health systems to achieve this goal. Purchasing is one such reform areas and evidence suggests that better progress can be made if purchasing could be done strategically rather than passive. Consequently, there is a need to continuously monitor progress and assess where further reforms may need to be designed or implemented.
This a progress matrix indicating the progress Kenya has made in strategic health purchasing and the remaining gaps across three main purchasers: The Ministry of Health, The National Hospital Insurance Fund and the County Departments of Health. This template was created by the Strategic Purchasing Africa Resource Centre (SPARC)
A Critical Analysis of Purchasing Arrangements in Kenya: The Case of the National Hospital Insurance Fund
No full textAbstract
Background: Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of
health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries
(LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the
National Hospital Insurance Fund (NHIF) as a case study.
Methods: We applied a principal-agent relationship framework, which identifies three pairs of principal-agent
relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within
them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through
document reviews (statutes, policy and regulatory documents) and in-depth interviews (n=62) with key informants
including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers.
Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed
using a thematic framework approach.
Results: The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear
accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed
over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting,
monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical
distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing
needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist,
they do not always function appropriately and awareness of these channels to the beneficiaries is limited.
Conclusion: Addressing the gaps in the NHIF’s purchasing performance requires a number of approaches. Critically,
there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the
multiplicity of actors given Kenya’s devolved context. Relatively recent decentralisation reforms present an opportunity
that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal
health coverage (UHC)
Understanding factors influencing the use of clinical guidelines in low-income and middle-income settings: a scoping review
No full textObjective A scoping review was undertaken to determine the extent to which existing studies have examined factors influencing healthcare providers’ use of clinical guidelines in low and middle-income country (LMIC) settings and determine which factors constrain or facilitate the use of clinical guidelines by healthcare providers.Design Scoping review.Data sources The literature search was conducted using PubMed in January 2021.Eligibility criteria We identified empirical studies, published between 2011–2021 in English, which included clinicians and/or nurses as healthcare providers, used a health facility as the study site, and were located in an LMIC.Data extraction and synthesis Information extracted from the literature review was organised using themes and the findings synthesised using thematic analysis.Results The review identified five types of interacting factors that influence healthcare providers’ use of and compliance with clinical guidelines. The factors identified are organisational factors, factors relating to individual healthcare providers, attributes of the clinical guidelines, patient-related factors and institutional factors. Organisational factors can be further divided into the physical work environment, organisational culture and working conditions. The effective use of clinical guidelines in LMIC settings is greatly impacted by the contextualisation of clinical guidelines, end-user engagement and alignment of the implementation of clinical guidelines with the institutional arrangements in the broader health system.Conclusion The development and evaluation of concrete interventions is vital to facilitate the implementation of clinical guidelines and improve healthcare service quality. Further studies are necessary to examine the relative importance of the five identified factors on the effective use of clinical guidelines in different contexts
Examining the Implementation Experience of the Universal Health Coverage Pilot in Kenya
No full textThe Kenyan government implemented a Universal Health Coverage (UHC) pilot project in four (out of 47) counties in 2019 to address supply-side gaps and remove user fees at county referral hospitals. The objective of this study was to examine the UHC pilot implementation experience using a mixed-methods cross-sectional study in the four UHC pilot counties (Isiolo, Kisumu, Machakos, and Nyeri). We conducted exit interviews (n = 316) with health facility clients, in-depth interviews (n = 134) with national and county-level health sector stakeholders, focus group discussions (n = 22) with community members, and document reviews. We used a thematic analysis approach to analyze the qualitative data and descriptive analysis for the quantitative data. The UHC pilot resulted in increased utilization of healthcare services due to removal of user fees at the point of care and increased availability of essential health commodities. Design and implementation challenges included: a lack of clarity about the relationship between the UHC pilot and existing health financing arrangements, a poorly defined benefit package, funding flow challenges, limited healthcare provider autonomy, and inadequate health facility infrastructure. There were also persistent challenges with the procurement and supply of healthcare commodities and with accountability mechanisms between the Ministry of Health and county health departments. The study underscores the need for whole-system approaches to healthcare reform in order to ensure that the capacity to implement reforms is strengthened, and to align new reforms with existing system features
