Tracking implementation and (un)intended consequences: a process evaluation of an innovative peripheral health facility financing mechanism in Kenya.

In many African countries, user fees have failed to achieve intended access and quality of care improvements. Subsequent user fee reduction or elimination policies have often been poorly planned, without alternative sources of income for facilities. We describe early implementation of an innovative national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are managed by health facility management committees (HFMCs) including community representatives. HSSF is therefore a finance mechanism with potential to increase access to funds for peripheral facilities, support user fee reduction and improve equity in access. We conducted a process evaluation of HSSF implementation based on a theory of change underpinning the intervention. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. We found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involvement; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; interactions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, national reduction policies were still not being adhered to. Finance mechanisms can have a strong positive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and ensure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need. Process evaluations tracking (un)intended consequences of interventions can contribute to regional financing and decentralization debates

Review of Health Sector Services Fund Implementation and Experience

The Health Sector Services Fund (HSSF) is an innovative scheme established by the Government of Kenya (GOK) to disburse funds directly to health facilities to enable them to improve health service delivery to local communities. HSSF empowers local communities to take charge of their health by actively involving them through the Health Facility Management Committees (HFMCs) in the identification of their health priorities and in planning and implementation of initiatives responsive to the identified priorities. Following a successful pilot of a similar mechanism, the strategy was scaled up nationwide, starting in 2010. Following the recent general election in Kenya, dramatic changes to the health system are being considered and introduced, including devolution of government functions to 47 semi-autonomous counties, the merging of the two ministries of health, and the abolition of user fees at health centres and dispensaries. Given the experience of nearly 3 years of HSSF implementation, and the context of these important changes in the organisation of health service delivery, a review of experiences to date with HSSF and key issues to consider moving forward is timely. The overall goal of HSSF is to generate sufficient resources for providing adequate curative, preventive and promotive services at community, dispensary and health centre levels, and to account for the resources in an efficient and transparent manner. HSSF can cover items such as facility operations and maintenance, refurbishment, support staff, allowances, communications, utilities, non-drug supplies, fuel and community based activities. DANIDA and the World Bank are currently partnering with the MOPHS in supporting the HSSF’s phased implementation which began in October 2010 with public health centres, and public dispensaries in July 2012. Following a facility stakeholder’s forum, HFMCs should develop annual work plans (AWPs) and quarterly implementation plans (QIPs). HSSF resources are credited directly to each designated facility’s bank account every quarter and to the District Health Management Team (DHMT): KSH 112,000 (1,339 USD) for health centres, KSH 27,500 (327 USD) for dispensaries and 131,500 (1,565 USD) for DHMTs. Other funds available to the facility, such as user fee revenue, and grants and donations received locally, should be banked in the same account, and managed and accounted for together with HSSF funds from national level. All funds should be managed by the Health Facility Management Committee (HFMC) which includes community representatives, according to the financial guidelines approved by the Ministry of Health (MOH). Funds can only be spent on receipt of an Authority to Incur Expenditure (AIE) from national level. Facilities must then account for funds using monthly and quarterly financial reports, and expenditures are recorded in a specific software called Navision. Facility level supervision and support is provided by the DHMT and county based accountants (CBAs) hired specifically for HSSF; and at national level HSSF oversight is provided by the National Health Sector Committee. This review had the following objectives: 1. To describe the process of HSSF implementation to date, including facilities covered, funds disbursed, and activities undertaken. 2. To review evidence on the experience with HSSF implementation 3. To identify key issues including devolution for consideration in future planning around HSSF These objectives have been addressed through review of policy documents, administrative reports, and research studies related to HSSF; and interviews with key stakeholders in MOPHS, DANIDA and the World Bank, to obtain updates on HSSF implementation and experience

Human candidate gene polymorphisms and risk of severe malaria in children in Kilifi, Kenya: a case-control association study

Background: Human genetic factors are important determinants of malaria risk. We investigated associations between multiple candidate polymorphisms—many related to the structure or function of red blood cells—and risk for severe Plasmodium falciparum malaria and its specific phenotypes, including cerebral malaria, severe malaria anaemia, and respiratory distress. Methods: We did a case-control study in Kilifi County, Kenya. We recruited as cases children presenting with severe malaria to the high-dependency ward of Kilifi County Hospital. We included as controls infants born in the local community between Aug 1, 2006, and Sept 30, 2010, who were part of a genetics study. We tested for associations between a range of candidate malaria-protective genes and risk for severe malaria and its specific phenotypes. We used a permutation approach to account for multiple comparisons between polymorphisms and severe malaria. We judged p values less than 0·005 significant for the primary analysis of the association between candidate genes and severe malaria. Findings: Between June 11, 1995, and June 12, 2008, 2244 children with severe malaria were recruited to the study, and 3949 infants were included as controls. Overall, 263 (12%) of 2244 children with severe malaria died in hospital, including 196 (16%) of 1233 with cerebral malaria. We investigated 121 polymorphisms in 70 candidate severe malaria-associated genes. We found significant associations between risk for severe malaria overall and polymorphisms in 15 genes or locations, of which most were related to red blood cells: ABO, ATP2B4, ARL14, CD40LG, FREM3, INPP4B, G6PD, HBA (both HBA1 and HBA2), HBB, IL10, LPHN2 (also known as ADGRL2), LOC727982, RPS6KL1, CAND1, and GNAS. Combined, these genetic associations accounted for 5·2% of the variance in risk for developing severe malaria among individuals in the general population. We confirmed established associations between severe malaria and sickle-cell trait (odds ratio [OR] 0·15, 95% CI 0·11–0·20; p=2·61 × 10−58), blood group O (0·74, 0·66–0·82; p=6·26 × 10−8), and –α3·7-thalassaemia (0·83, 0·76–0·90; p=2·06 × 10−6). We also found strong associations between overall risk of severe malaria and polymorphisms in both ATP2B4 (OR 0·76, 95% CI 0·63–0·92; p=0·001) and FREM3 (0·64, 0·53–0·79; p=3·18 × 10−14). The association with FREM3 could be accounted for by linkage disequilibrium with a complex structural mutation within the glycophorin gene region (comprising GYPA, GYPB, and GYPE) that encodes for the rare Dantu blood group antigen. Heterozygosity for Dantu was associated with risk for severe malaria (OR 0·57, 95% CI 0·49–0·68; p=3·22 × 10−11), as was homozygosity (0·26, 0·11–0·62; p=0·002). Interpretation: Both ATP2B4 and the Dantu blood group antigen are associated with the structure and function of red blood cells. ATP2B4 codes for plasma membrane calcium-transporting ATPase 4 (the major calcium pump on red blood cells) and the glycophorins are ligands for parasites to invade red blood cells. Future work should aim at uncovering the mechanisms by which these polymorphisms can result in severe malaria protection and investigate the implications of these associations for wider health. Funding: Wellcome Trust, UK Medical Research Council, European Union, and Foundation for the National Institutes of Health as part of the Bill & Melinda Gates Grand Challenges in Global Health Initiative

How does Public Financial Management (PFM) influence health system efficiency: A scoping review

BackgroundEffective Public Financial Management (PFM) approaches are imperative in the quest for efficiency in health service delivery. Reviews conducted in this area have assessed the impact of PFM approaches on health system efficiency but have left out the mechanisms through which PFM influences efficiency. This scoping review aims to synthesize evidence on the mechanisms by which PFM influences health system efficiency.MethodsWe searched databases of PubMed and Google Scholar and websites of the World Health Organization (WHO), World Bank and Overseas Development Institute (ODI) for peer-reviewed and grey literature articles that provided data on the relationship between PFM and health system efficiency. Three reviewers screened the articles for eligibility with the inclusion criteria. Data on PFM and health system efficiency was charted and summarized. We then reported the mechanisms by which PFM influence efficiency.ResultsPFM processes and structures influence health system efficiency by influencing; the alignment of resources to health system needs, the cost of inputs, the motivation of health workers, and the input mix.ConclusionThe entire budget process influences health system efficiency. However, most of the findings are drawn from studies that focused on aspects of the budget process. Studies that look at PFM in totality will help explore other cross-cutting issues within sections of the budget cycle; they will also bring out the relationship between the different phases of the budget cycle

How does decentralisation affect health sector planning and financial management? a case study of early effects of devolution in Kilifi County, Kenya

A common challenge for health sector planning and budgeting has been the misalignment between policies, technical planning and budgetary allocation; and inadequate community involvement in priority setting. Health system decentralisation has often been promoted to address health sector planning and budgeting challenges through promoting community participation, accountability, and technical efficiency in resource management. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous devolved county governments, and a substantial transfer of responsibility for healthcare from the central government to these counties

Describing and evaluating healthcare priority setting practices at the county level in Kenya.

BACKGROUND:Healthcare priority setting research has focused at the macro (national) and micro (patient level), while there is a dearth of literature on meso-level (subnational/regional) priority setting practices. In this study, we aimed to describe and evaluate healthcare priority setting practices at the county level in Kenya. METHODS:We used a qualitative case study approach to examine the planning and budgeting processes in 2 counties in Kenya. We collected the data through in-depth interviews of senior managers, middle-level managers, frontline managers, and health partners (n = 23) and document reviews. We analyzed the data using a framework approach. FINDINGS:The planning and budgeting processes in both counties were characterized by misalignment and the dominance of informal considerations in decision making. When evaluated against consequential conditions, efficiency and equity considerations were not incorporated in the planning and budgeting processes. Stakeholders were more satisfied and understood the planning process compared with the budgeting process. There was a lack of shifting of priorities and unsatisfactory implementation of decisions. Against procedural conditions, the planning process was more inclusive and transparent and stakeholders were more empowered compared with the budgeting process. There was ineffective use of data, lack of provisions for appeal and revisions, and limited mechanisms for incorporating community values in the planning and budgeting. CONCLUSION:County governments can improve the planning and budgeting processes by aligning them, implementing a systematic priority setting process with explicit resource allocation criteria, and adhering to both consequential and procedural aspects of an ideal priority setting process

Relationship between Student Anxiety and Achievement in Mathematics among Secondary School Students in Ganze District Kilifi County Kenya

This article is based on a bigger study which sought to establish the relationship between affective factors with students` achievement in mathematics. The article shares findings from the study objective to establish the relationship between student anxiety and achievement in mathematics. Descriptive Survey research design on a sample size of 250 students used a mathematics anxiety rating scale and mathematics achievement test to collect quantitative data. The computational formula of Pearson`s product-moment correlation coefficient  determined the null hypothesis, “there is no statistically significant relationship between student anxiety and achievement in mathematics”. The study found that there was a statistically significant positive correlation coefficient of  between student anxiety and achievement in mathematics. This implies that student anxiety is indirectly proportional to achievement in mathematics. However, analysis based on gender differences contradicts the stereotype that females are always of higher anxiety levels towards mathematics than males. Males in mixed-boarding and mixed-day secondary schools indicated lower anxiety levels than females, unlike in single-sex boarding secondary schools where both genders indicated similar anxiety levels towards mathematics. The study recommends mathematics teachers have to build up friendly situation that avoids anxiety in a classroom environment for better achievement since student anxiety is indirectly proportional to achievement in mathematic

Devolution and its effects on health workforce and commodities management – early implementation experiences in Kilifi County, Kenya

BACKGROUND: Decentralisation is argued to promote community participation, accountability, technical efficiency, and equity in the management of resources, and has been a recurring theme in health system reforms for several decades. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous county governments, with substantial transfer of responsibility for health service delivery from the central government to these counties. Focusing on two key elements of the health system, Human Resources for Health (HRH) and Essential Medicines and Medical Supplies (EMMS) management, we analysed the early implementation experiences of this major governance reform at county level. METHODS: We employed a qualitative case study design, focusing on Kilifi County, and adapted the decision space framework developed by Bossert et al., to guide our inquiry and analysis. Data were collected through document reviews, key informant interviews, and participant and non-participant observations between December 2012 and December 2014. RESULTS: As with other county level functions, HRH and EMMS management functions were rapidly transferred to counties before appropriate county-level structures and adequate capacity to undertake these functions were in place. For HRH, this led to major disruptions in staff salary payments, political interference with HRH management functions and confusion over HRH management roles. There was also lack of clarity over specific roles and responsibilities at county and national government, and of key players at each level. Subsequently health worker strikes and mass resignations were witnessed. With EMMS, significant delays in procurement led to long stock-outs of essential drugs in health facilities. However, when the county finally managed to procure drugs, health facilities reported a better order fill-rate compared to the period prior to devolution. CONCLUSION: The devolved government system in Kenya has significantly increased county level decision-space for HRH and EMMS management functions. However, harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system, and to build capacity of the counties to undertake certain specific HRH and EMMS management tasks. Capacity considerations should always be central when designing health sector decentralisation policies

Examining the effects of political decentralisation in Kenya on health sector planning and budgeting: a case study of Kilifi County.

Health sector decentralisation has been a recurring theme in health systems reform discourse for several decades, particularly in developing countries. Decentralisation is promoted for its ability to strengthen community participation and accountability, and to enhance technical efficiency in the management of limited health sector resources. However, most of the literature on health sector decentralisation has been descriptive, reporting outcomes of different decentralisation models, with minimal analysis of how contextual factors contribute to the observed outcomes. In 2010, Kenya passed a new constitution through a nationwide public referendum. A key feature of this constitution was the introduction of 47 semi-autonomous devolved county governments. This study aimed to describe and analyse the effects of this major political decentralization on planning and budgeting in the health sector at the sub-national level, including the goals and intended strategies for health sector operational planning and budgeting, and stakeholder expectations and experiences of decentralisation. I used a case study design, focusing on Kilifi County, guided by a conceptual framework which drew on decentralisation and policy analysis theories. I used three tracers: planning and budgeting for recurrent expenditures; Human Resources for Health (HRH); and Essential Medicines and Medical Supplies (EMMS) management. I collected qualitative data through document reviews, key informant interviews, and participant and non-participant observations. I found that the Kenyan devolution was largely driven by the need to address political rather that technical challenges in public sector management. To this effect, county level functions were rapidly transferred without proper structures and capacity to undertake these functions leading to major disruption of public services at county level. Within the health sector, the early days witnessed perverse re-centralisation of operational financial management roles from health facility level to the county level. On HRH, there were major disruptions in staff salary payments, political interference with HRH management functions and confusion over certain HRH management roles; leading to industrial strikes and mass resignations by health workers. On EMMS, there were significant delays in the procurement process leading to long periods of stock outs of essential drugs in health facilities. With time though, and with the county governments establishing their structures and progressively building their capacity, a general improvement in counties’ ability to manage devolved functions, including health sector functions has been witnessed and there are deliberate efforts to find local level solutions to some of the emerging challenges. In conclusion I argue that the political push for decentralisation is often stronger than the technical intentions and implementation processes. There is thus need for health sector policy actors to have a broader understanding of the countries’ political context whenever designing technical strategies for implementing health sector decentralisation. In addition, I propose that the allocation of functions between central level and decentralised units should always be guided by considerations around decision space, organisational structure and capacity, and accountability arrangements and practices within the health system