Tracking implementation and (un)intendedconsequences of peripheral health facility

financing mechanisms in Kenya

P4P workshop – Evelyn Waweru April 2015

POLICY PROCESS

CONTEXT ACTORS

Outline

▪ Background: Kenyan health sector policy reforms

▪ What is DFF and HSSF and how its supposed to work

▪ Experiences with implementation of HSSF

▪ Current proposal and way forward

NB: Peripheral health facilities = public health centres and dispensaries

Health Sector Services Fund (HSSF)

▪ Background: need to improve the efficiency, quality, equity and sustainability of primary care provision in developing countries and guided by global debates on UHC, decentralisation and community participation.

▪ 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

Parliament

Treasury

Central Bank of Kenya HSSF Account

HFMC (Facility Commercial Bank

Account)

FBO Facilities /Private Sector

Commercial Bank Accounts

Donors

Minister MOPHS

PS MOPHS

(HSSF Secretariat)

National Health Services Committee

DHMT Commercial Bank Account

Disbursement of funds

Authority to Incur Expenditure (AIE)

Funds distribution schedules

District Treasury

PHMT Commercial Bank Account

Ministry of Finance

HSSF Budget estimates

Budget Approval

HSSF Secretariat Commercial Bank

Account

Source: Guidelines on Financial Management for the Health Sector Services Fund

HSSF Funding and Disbursement Pathways

Funds transfer

▪ HSSF Funds cover: Facility operations and maintenance; should not cover: Drugs, personal expenses and non-voted items

▪ Planning: Involve stakeholders (HFMC) in making AWPs and QIPs which then translate to facility and sub-county budgets

▪ Funds managed by the HFMC:, according to financial guidelines approved by MOH

▪ Spending: only on receipt of an Authority to Incur Expenditure (AIE) from national level

▪ Accounting and financial management: facility monthly reports counter-checked by county accountant

▪ Supportive supervision: DHMT and (CBAs) hired specifically

How should HSSF work

Experiences with HSSF implementation

Key research findings▪ Coast pilot: small increases in

the funding available for the day to day running of facilities greatly improved facility functioning and perceived quality of care

▪ 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, there was need for an overall increase in inputs:

Health Policy and Planning

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

HSSF Interim process evaluation: Findings

▪ 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

Perceived positive impacts▪ Funds were reaching facilities ▪ Visible improvements in facilities ▪ More reported outreach activities ▪ Improved perceived quality of care, staff

motivation and patient satisfaction “of course the quality of care has improved; initially if you didn’t have gloves you would tell a client- sorry we can’t help you” (Health Centre In-charge)

▪ Participation, transparency and accountability - Active involvement of community members through

HFMCs - Greater transparency and improved oversight of user fee

revenues

HSSF Implementation Challenges and ways of fixing them

Challenges in financing

▪ Delays in receiving funds: AIEs were also fixed “a straight jacket on HSSF because they had given us sort of an AIE …it has to be utilized on the item which is indicated ” (HFMC member) – fixed by annual AIEs; working on flow of funds

▪ Inadequate level of funds – working on increasing county buy in and discussions with donors on a pooling system

▪ Compensation for removed user fees – flat rate, RAC and utilisation

▪ Low allowances for HFMCs “peanuts” no incentives for staff – mixed opinions

▪ Different donor opinions “the lack of the involvement of the district treasury is the Achilles heel of HSSF” (National KI) – ongoing dialogue with donors and the Council of Governors

Supportive supervision and accountability

▪ Lack of training on financial management

▪ Lack of facilitation and systematic M&E

▪ Understanding of roles and responsibilities

▪ Overworked CBAs

▪ Reluctant in-charges “Kwamad with terror” (National KI)

[At the DHMT level] you are actually doing an accountant’s work and you’ve never trained for it ...you can be taught for 3 days or 5 days and you think you get it, [but] you keep on forgetting … (DHMT member).

Unintended consequences

▪ Complex reporting and documentation: time consuming – priority documents to submit to CBA

▪ Difficulties in adhering to the rules of spending: flexibility – need for clear and comprehensive guidelines

▪ Bypassing the district treasury – They (CBAs) are not linked with the District Treasury for

technical support and integration within DHMTs remains weak and accountants are not always included during supervision visits to facilities’ (2013 Aide Memoire). – still an issue with the county treasury now having more decision power over county spending

   ▪ Relationship problems between key stakeholders

– Diff views on how HSSF should work after devolution – compounded by devolution and politicians influence on the HFMC

Items required for financial management of HSSF at facility level

(Source: Managing the HSSF – An Operations Guide)

Guidelines and Reference Documents • Managing the HSSF – An Operations Guide • Guidelines on Financial Management for HSSF • Chart of Accounts

Registers / Books to be completed • Memorandum Vote Book (MVB) • Receipt Book • Facility Service Register (FSR) • Cash Book • Cheque Book Register • Fixed Assets Register • Imprest Register • Consumables Stock Register • Store Register • Counter Receipt Book Register

Other items • Cheque book

Forms / Vouchers  • Receipt Vouchers (F017) • Payment Vouchers (F021) • Travel Imprest Form (F022) • Local Purchase Orders (LPO) • Local Service Orders (LSO) • Request for Quotations (RFQ) • Stock Cards for all items in stores • Imprest Warrants • Bank Reconciliation forms (F030) • Counter Requisition and Issue Vouchers (S11) • Counter Receipt Vouchers (S13) • Handover Forms • Monthly Service Delivery Report Forms

(MOH105) • Monthly Financial Report forms (MFR) • Monthly Expenditure Report forms (MER) • Quarterly Financial Report forms (QFR)

Only financial! There are numerous other daily registers and monthly reports to fill

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?

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 • PBF?

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

regulationsInternal & community

accountability

Health worker motivation

 

Perceived Quality of

care

Utilisation

 

5 key decision making domains: theory and practice

Way forward?▪ Different counties different health system structures

and varying levels of control of funds ▪ New financing mechanisms:

– Reimbursements for user fees (flat rate, with talks of linking amounts to facility utilisation)

– Reimbursements for free maternity health services (2500 per delivery)

– DANIDA funds (last financial year) – NHIF? – OBA: selected counties (complementary to FMS but with

staff incentives) – PBF: pilot

▪ Data analysis and feedback – research to policy, implementation research?

▪ Next steps: PBF checklist?

Knowledge Gaps around HSSF

• Continuity, transition period, future politics

• Flexibility in design o funds be controlled at county of national level? o integrated into standard government financial

systems? Role of insurance? o performance related?

• Best methods for evaluation – and balancing mixed methods

Acknowledgements▪ Supervisors: Drs Sassy

Molyneux, Catherine Goodman

▪ Co-investigators: Benjamin Tsofa, Mary Nyikuri, Jacinta Nzinga, Edwine Barasa, Jane Chuma, Anisa Omar, Timothy Malingi

▪ Research participants