Examining health sector application and utility of program-based budgeting: County level experiences in Kenya.

INTRODUCTION: In 2012, Kenya enacted a new Public Finance Management Act to guide the public-sector planning and budgeting process. This new law replaced the previous line item budgeting, with a new program-based budgeting (PBB) process. This study examined the experience of health sector PBB implementation at the county level in Kenya. METHODS: We carried out a review of the literature documenting the health sector application and utility of PBB in low- and middle-income countries. We then collected empirical data to examine the experience of health sector application of PBB at County Level in Kenya. RESULTS: In the financial year 2017/18, counties utilised the PBB approach for health sector planning. The PBB approach was perceived by key stakeholders; to have improved the alignment of technical priorities with budgetary allocation, and to have increased transparency, accountability and openness of the process. Its challenges included lack of clear tools and guidelines to support implementation, low capacity at county level, political interference and the organisation of the public sector electronic financial management system around line item budgeting system. CONCLUSION: PBB is potentially a useful tool for aligning health sector planning and budgeting and ensuring the Annual Work Plan is more result oriented. However, realisation of this goal would be enhanced by the developing clear tools and guidelines to support its implementation, building capacity for county health sector managers to better understand the PBB application, and reforming the public-sector budgetary management system to align it with the PBB approach.

Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya.

BACKGROUND: Monitoring the incidence and intensity of catastrophic health expenditure, as well as the impoverishing effects of out of pocket costs to access healthcare, is a key part of benchmarking Kenya's progress towards reducing the financial burden that households experience when accessing healthcare. METHODS: The study relies on data from the nationally-representative Kenya Household Expenditure and Utilization Survey conducted in 2013 (n =33,675). We undertook health equity analysis to estimate the incidence and intensity of catastrophic expenditure. Households were considered to have incurred catastrophic expenditures if their annual out of-pocket health expenditures exceeded 40% of their annual non-food expenditure. We assessed the impoverishing effects of out of pocket payments using the Kenya national poverty line. We distinguished between direct payments for healthcare such as payments for consultation, medicines, medical procedures, and total healthcare expenditure that includes direct healthcare payments and the cost of transportation to and from health facilities. We used logistic regression analysis to explore the factors associated with the incidence of catastrophic expenditures. RESULTS: When only direct payments to healthcare providers were considered, the incidence of catastrophic expenditures was 4.52%. When transport costs are included, the incidence of catastrophic expenditure increased to 6.58%. 453,470 Kenyans are pushed into poverty annually as a result of direct payments for healthcare. When the cost of transport is included, that number increases by more than one third to 619,541. Unemployment of the household head, presence of an elderly person, a person with a chronic ailment, a large household size, lower household social-economic status, and residence in marginalized regions of the country are significantly associated with increased odds of incurring catastrophic expenditures. CONCLUSIONS: Kenyan policy makers should prioritize extending pre-payment mechanisms to more vulnerable groups, specifically the poor, the elderly, those suffering from chronic ailments and those living in marginalized regions of the country. The range of services covered under these mechanisms should also be extended such that the proportion of direct costs paid to access care is reduced. Policy makers should also prioritize reducing supply side bottlenecks such as availability of healthcare facilities in close proximity to the population, especially in rural and marginalized areas, and improvements in quality of care. For the poor and the vulnerable, initiatives to cover the cost of transport to and from a health facility, such as transport vouchers could also be explored.

Historical account of the national health insurance formulation in Kenya: experiences from the past decade.

BACKGROUND: Many Low-and-Middle-Income countries are considering reviewing their health financing systems to meet the principles of Universal Health Coverage (UHC). One financing mechanism, which has dominated UHC reforms, is the development of health insurance schemes. We trace the historical development of the National Health Insurance (NHI) policy, illuminate stakeholders' perceptions on the design to inform future development of health financing policies in Kenya. METHODS: We conducted a retrospective policy analysis of the development of a NHI policy in Kenya using data from document reviews and seven in depth interviews with key stakeholders involved in the NHI design. Analysis was conducted using a thematic framework. RESULTS: The design of a NHI scheme was marked by complex interaction of the actor's understanding of the design, proposed implementation strategies and the covert opposition of the reform due to several reasons. First, actor's perception of the cost of the NHI design and its implication to the economy generated opposition. This was due to inadequate communication strategies to articulate the policy, leading to a vacuum of factual information flow to various players. Secondly, perceived fear of implications of the changes among private sector players threatened support and success gained. Thirdly, underlying mistrust associated with perceived lack of government's commitment towards transparency and good governance affected active engagement of all key players dampening the spirit of collective bargain breeding opposition. Finally, some international actors perceived a clash of their role and that of international programs based on vertical approaches that were inherent in the health system. CONCLUSION: The thrust towards UHC using NHI schemes should not only focus on the design of a viable NHI package but should also involve stakeholder engagements, devise ways of improving the health care system, enhance transparency and develop adequate governance structures to institutions mandated to provide leadership in the reform process to overcome covert opposition.

Reproductive health financing in Kenya: an analysis of national commitments, donor assistance, and the resources tracking process.

Understanding the flow of resources at the country level to reproductive health is essential for effective financing of this key component of health. This paper gives a comprehensive picture of the allocation of resources for reproductive health in Kenya and the challenges faced in the resource-tracking process. Data are drawn from Kenyan budget estimates, reproductive health accounts, and the Resource Flows Project database and compare budgets and spending in 2005-06 with 2009-10. Despite policies and programmes in place since 1994, services for family planning, maternity care and infant and child health face serious challenges. As regards health financing, the government spends less than the average in sub-Saharan Africa, while donor assistance and out-of-pocket expenditure for health are high. Donor assistance to Kenya has increased over the years, but the percentage of funds devoted to reproductive health is lower than it was in 2005. We recommend an increase in the budget and spending for reproductive health in order to achieve MDG targets on maternal mortality and universal access to reproductive health in Kenya. Safety nets for the poor are also needed to reduce the burden of spending by households. Lastly, we recommend the generation of more comprehensive reproductive health accounts on a regular basis.

Catastrophic health care spending and impoverishment in Kenya.

BACKGROUND: Many health systems in Africa are funded primarily through out-of-pocket payments. Out-of-pocket payments prevent people from seeking care, can result to catastrophic health spending and lead to impoverishment. This paper estimates the burden of out-of-pocket payments in Kenya; the incidence and intensity of catastrophic health care expenditure and the effect of health spending on national poverty estimates. METHODS: Data were drawn from a nationally representative health expenditure and utilization survey (n = 8414) conducted in 2007. The survey provided detailed information on out-of-pocket payments and consumption expenditure. Standard data analytical techniques were applied to estimate the incidence and intensity of catastrophic health expenditure. Various thresholds were applied to demonstrate the sensitivity of catastrophic measures. RESULTS: Each year, Kenyan households spend over a tenth of their budget on health care payments. The burden of out-of-pocket payments is highest among the poor. The poorest households spent a third of their resources on health care payments each year compared to only 8% spent by the richest households. About 1.48 million Kenyans are pushed below the national poverty line due to health care payments. CONCLUSIONS: Kenyans are becoming poorer due to health care payments. The need to protect individuals from health care related impoverishment calls for urgent reforms in the Kenyan health system. An important policy question remains what health system reforms are needed in Kenya to ensure that financial risk protection for all is achieved.

Does the distribution of health care benefits in Kenya meet the principles of universal coverage?

BACKGROUND: The 58th World Health Assembly called for all health systems to move towards universal coverage where everyone has access to key promotive, preventive, curative and rehabilitative health interventions at an affordable cost. Universal coverage involves ensuring that health care benefits are distributed on the basis of need for care and not on ability to pay. The distribution of health care benefits is therefore an important policy question, which health systems should address. The aim of this study is to assess the distribution of health care benefits in the Kenyan health system, compare changes over two time periods and demonstrate the extent to which the distribution meets the principles of universal coverage. METHODS: Two nationally representative cross-sectional households surveys conducted in 2003 and 2007 were the main sources of data. A comprehensive analysis of the entire health system is conducted including the public sector, private-not-for-profit and private-for-profit sectors. Standard benefit incidence analysis techniques were applied and adopted to allow application to private sector services. RESULTS: The three sectors recorded similar levels of pro-rich distribution in 2003, but in 2007, the private-not-for-profit sector was pro-poor, public sector benefits showed an equal distribution, while the private-for-profit sector remained pro-rich. Larger pro-rich disparities were recorded for inpatient compared to outpatient benefits at the hospital level, but primary health care services were pro-poor. Benefits were distributed on the basis of ability to pay and not on need for care. CONCLUSIONS: The principles of universal coverage require that all should benefit from health care according to need. The Kenyan health sector is clearly inequitable and benefits are not distributed on the basis of need. Deliberate efforts should be directed to restructuring the Kenyan health system to address access barriers and ensure that all Kenyans benefit from health care when they need it.

Reversing the trend of weak policy implementation in the Kenyan health sector?--a study of budget allocation and spending of health resources versus set priorities.

BACKGROUND: Policy implementation in the context of health systems is generally difficult and the Kenyan health sector situation is not an exception. In 2005, a new health sector strategic plan that outlines the vision and the policy direction of the health sector was launched and during the same year the health sector was allocated a substantial budget increment. On basis of these indications of a willingness to improve the health care system among policy makers, the objective of this study was to assess whether there was a change in policy implementation during 2005 in Kenya. METHODOLOGY: Budget allocations and actual expenditures compared to set policy objectives in the Kenyan health sector was studied. Three data sources were used: budget estimates, interviews with key stakeholders in the health sector and government and donor documentation. RESULTS: Budget allocations and actual expenditures in part go against policy objectives. Failures to use a significant proportion of available funds, reallocation of funds between line items and weak procurements systems at the local level and delays in disbursement of funds at the central level create gaps between policy objectives and policy implementation. Some of the discrepancy seems to be due to a mismatch between responsibilities and capabilities at different levels of the system. CONCLUSION: We found no evidence that the trend of weak policy implementation in the Kenyan health sector was reversed during 2005 but ongoing efforts towards hastening release of funds to the districts might help solving the issue of low absorption capacity at the district level. It is important, however, to work with clear definitions of roles and responsibilities and well-functioning communications between different levels of the system.