2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

HEALTH SECTOR SERVICES FUNDA nationwide GoK fund to support a sector wide approach to resources for primary care facilitiesHSSF resources are credited directly to each designated facilitys bank account, and managed by the HFCThe HFC has 7-9 members, including at least 3 females:4 catchment area residents (ordinary community members)4 ex-officio members (health facility in-charge and representatives of: provincial administration; DMOH; and local authority facilities) Committee prepares a work plan based on guidelinesFunds can cover operations and maintenance, refurbishment, support staff, allowances, utilities, community based activitiesEnhances community/facility/district management communication

WITHOUT HSSFWITH HSSF

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

STUDY OBJECTIVESBroad ObjectiveCollect and present nationally representative data on HFCs in Kenya in advance of the introduction of HSSF nationallySpecific ObjectivesDocument HFC characteristics and operationsAssess patient awareness of their activitiesDescribe roles and benefits of HFC membersExplore HFC members motivation and job satisfaction

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

STUDY DESIGNCluster randomized sample of facilitiesRandomly selected 24 districtsThree non-municipal districts per Province (excl. Nairobi)Three municipal districts

Selected random sample of facilities in each district, stratified by facility typeFacility sampling frame included all facilities eligible to receive HSSFSelected up to 7 health centres and 7 dispensaries in each district

*DATACOLLECTION

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

DATA COLLECTIONData collected: July September 2010Structured survey at each facility:Interview with the facility in-chargeSelf-administered questionnaire for the In-Charge on motivation and empowermentInterviews with 2 HFC membersExit interviews with 3 outpatients (curative care)Collection of contextual data at the district level

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

DATA ANALYSISUsed Stata v. 11 for cleaning and analysisUsed survey commands to account for:Variation in sampling probability across facilities using pweightsStratification by province and health facility typeClustering at the district and facility level

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

SUMMARY OF DATA COLLECTED

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

KEY FINDINGS IN RELATION TO:HFC membership, selection and characteristics, and trainingPatient awareness of HFCsPerceived roles of HFCsHFC meetings, allowances, benefits and constraintsHFC/in-charge relationshipsHFC motivation

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

HFC MEMBERSHIP AND SELECTION97.2% of the facilities sampled had HFCs

Median of 10 members per HFC23.3% HFCs included all types of members in the Government Gazette58.8% joined the HFC between 1 and 5 years ago 18.5% in the last year Most HFC members reported being selected at a Baraza (72.2%)

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

HFC MEMBERS CHARACTERISTICSAge: all 25 years or over, with just over half aged 45 years or aboveOccupation: mostly business/trade (25.6%) and subsistence farming (24.4%)Education: half (53.2%) completed secondary schoolResidence: Most (65.1%) lived less than 30 minutes walk away from the facility they servedGender: 30.0% of all HFC members were femaleCHW training: Just under half (44.8%) reported having been trained as community health workers

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

HFC MEMBER TRAININGTraining in facility/financial management: In 26.7% of facilities, one or more health workers were trained (24.4% in non-municipal dispensaries to 82.4% in non-municipal health centres)About half of HFC members (50.1%) reported having received training, slightly more in health centres than in dispensaries

Patient Awareness of HFCs

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

PERCEPTIONS OF HFC ROLES (CONT.)In-charges described HFC roles in similar ways, but only 34.5% considered supervision of facility staff an HFC role (as opposed to 61.9% of HFC members)

Users of facilities often did not know HFC responsibilities. For example, many did not know whether it was HFCs role to:Set the level of user fees (24.7% users) Contribute to the development of annual work plans (22.3%)Decide on how facility funds are utilized (19.3%)

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

HFC MEETINGS AND ALLOWANCES (IN-CHARGE RESPONSES)Of facilities with HFCs:77.9% held a full committee meeting in the last quarter (median n=1)Half held smaller executive meetings (median n=1)53.1% received allowances for full meetings; 29.5% received allowances for executive meetings Median allowances where paid were KES 200

RELATIONSHIPS

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

RELATIONSHIP BETWEEN HFC MEMBERS AND THE IN-CHARGE: POSITIVE> 80% of HFC members agreed/strongly agreed:It is useful to hear the views of the facility in-charge during HFC meetings I believe that the in-charge works in the interest of this facility > 80% of in-charges agreed/strongly agreed:The health workers and the community members of the HFC work well together If I have better knowledge, the HFC are willing to accept advice from me

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

RELATIONSHIP BETWEEN HFC MEMBERS AND THE IN-CHARGE: CONCERNS13.9% of HFC members and 47.9% of in-charges agreed with the following statement:Tensions between the in-charge and committee members undermine the committees achievements 11.5% of HFC members agreed with the statement:The facility incharge sometimes looks down on community members in the HFC

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

SUMMARYPresence of minimum requirementsBank accountHealth facility committeesHFC members awareness of their rolesPositive relationships : in-charges and HFC membersHFC seem highly motivatedSupportive supervision was not as frequentHFC were not content with their allowancesConcern of some tension between in-charges and HFC membersTraining

Positive FindingsSignificant Challenges

2nd Conference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th - 17th March 2011

SUGGESTIONS FOR FOLLOW-UPMonitor and evaluate of HFCs functions (audit)Sustainability: funding, HFC member incentivesFeasibility of performance based financing as a reward/incentive for high achieving facilitiesEmphasis on community participation and reportingHFC members ability to fully participate in HSSF planning and follow HSSF financial procedures

BETTER HEALTH BETTER DAYS

****GoK- Government of KenyaDHMT-District Health Management TeamPHMT-Provincial Health Management TeamDMOH-District Medical Officer of Health

***********44.5% exit interviewees were aware, lesser in municipal facilities.

*****By HFC members***