The impact of COVID-19 on health financing in Kenya.

Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions. Health system functions may also influence the health system's ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic.We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Purchasing arrangements: COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme's benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources. Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

Examining health facility financing in Kenya in the context of devolution.

BACKGROUND: How health facilities are financed affects their performance and health system goals. We examined how health facilities in the public sector are financed in Kenya, within the context of a devolved health system. METHODS: We carried out a cross-sectional study in five purposely selected counties in Kenya, using a mixed methods approach. We collected data using document reviews and in-depth interviews (no = 20). In each county, we interviewed county department of health managers and health facility managers from two and one purposely selected public hospitals and health center respectively. We analyzed qualitive data using thematic analysis and conducted descriptive analysis of quantitative data. RESULTS: Planning and budgeting: Planning and budgeting processes by hospitals and health centers were not standardized across counties. Budgets were not transparent and credible, but rather were regarded as "wish lists" since they did not translate to actual resources. Sources of funds: Public hospitals relied on user fees, while health centers relied on donor funds as their main sources of funding. Funding flows: Hospitals in four of the five study counties had no financial autonomy. Health centers in all study counties had financial autonomy. Flow of funds to hospitals and health centers in all study counties was characterized by unpredictability of amounts and timing. Health facility expenditure: Staff salaries accounted for over 80% of health facility expenditure. This crowded out other expenditure and led to frequent stock outs of essential health commodities. CONCLUSION: The national and county government should consider improving health facility financing in Kenya by 1) standardizing budgeting and planning processes, 2) transitioning public facility financing away from a reliance on user fees and donor funding 3) reforming public finance management laws and carry out political engagement to facilitate direct facility financing and financial autonomy of public hospitals, and 4) assess health facility resource needs to guide appropriate levels resource allocation.

Examining the implementation of the Linda Mama free maternity program in Kenya.

BACKGROUND: In 2013, Kenya introduced a free maternity policy in all public healthcare facilities. In 2016, the Ministry of Health shifted responsibility for the program, now called Linda Mama, to the National Hospital Insurance Fund (NHIF) and expanded access beyond public sector. This study aimed to examine the implementation of the Linda Mama program. METHODS: We conducted a mixed-methods cross-sectional study at the national level and in 20 purposively sampled facilities across five counties in Kenya. We collected data using in-depth interviews (n = 104), administered patient-exit questionnaires (n = 108), and carried out document reviews. Qualitative data were analysed using a framework approach while quantitative data were analysed descriptively. RESULTS: Linda Mama was designed and resulted in improved accountability and expand benefits. In practice however, beneficiaries did not access some services that were part of the revised benefit package. Second, out of pocket payments were still being incurred by beneficiaries. Health facilities in most counties had lost financial autonomy and had no access to reimbursements from NHIF for services provided; but those with financial autonomy were able to boost facility revenue and enhance service delivery. Further, fund disbursements from NHIF were characterised by delays and unpredictability. Implementation experiences reveal that there was inadequate communication, claim processing challenges and reimbursement rates were deemed insufficient. CONCLUSIONS: Our findings show that there are challenges associated with the implementation of the Linda Mama program and highlights the need for process evaluations for programs to track implementation, ensure continuous learning, and provide opportunities for course correcting programs' implementation.

Impact of free maternity policies in Kenya: an interrupted time-series analysis.

BACKGROUND: User fees have been reported to limit access to services and increase inequities. As a result, Kenya introduced a free maternity policy in all public facilities in 2013. Subsequently in 2017, the policy was revised to the Linda Mama programme to expand access to private sector, expand the benefit package and change its management. METHODS: An interrupted time-series analysis on facility deliveries, antenatal care (ANC) and postnatal care (PNC) visits data between 2012 and 2019 was used to determine the effect of the two free maternity policies. These data were from 5419 public and 305 private and faith-based facilities across all counties, with data sourced from the health information system. A segmented negative binomial regression with seasonality accounted for, was used to determine the level (immediate) effect and trend (month-on-month) effect of the policies. RESULTS: The 2013 free-maternity policy led to a 19.6% and 28.9% level increase in normal deliveries and caesarean sections, respectively, in public facilities. There was also a 1.4% trend decrease in caesarean sections in public facilities. A level decrease followed by a trend increase in PNC visits was reported in public facilities. For private and faith-based facilities, there was a level decrease in caesarean sections and ANC visits followed by a trend increase in caeserean sections following the 2013 policy.Furthermore, the 2017 Linda Mama programme showed a level decrease then a trend increase in PNC visits and a 1.1% trend decrease in caesarean sections in public facilities. In private and faith-based facilities, there was a reported level decrease in normal deliveries and caesarean sections and a trend increase in caesarean sections. CONCLUSION: The free maternity policies show mixed effects in increasing access to maternal health services. Emphasis on other accessibility barriers and service delivery challenges alongside user fee removal policies should be addressed to realise maximum benefits in maternal health utilisation.

Purchasing reforms and tracking health resources, Kenya.

As low- and middle-income countries undertake health financing reforms to achieve universal health coverage, there is renewed interest in making allocation of pooled funds to health-care providers more strategic. To make purchasing more strategic, countries are testing different provider payment methods. They therefore need comprehensive data on funding flows to health-care providers from different purchasers to inform decision on payment methods. Tracking funding flow is the focus of several health resource tracking tools including the System of Health Accounts and public expenditure tracking surveys. This study explores whether these health resource tracking tools generate the type of information needed to inform strategic purchasing reforms, using Kenya as an example. Our qualitative assessment of three counties in Kenya shows that different public purchasers, that is, county health departments and the national health insurance agency, pay public facilities through a variety of payment methods. Some of these flows are in-kind while others are financial transfers. The nature of flows and financial autonomy of facilities to retain and spend funds varies considerably across counties and levels of care. The government routinely undertakes different health resource tracking activities to inform health policy and planning. However, a good source for comprehensive data on the flow of funds to public facilities is still lacking, because these activities were not originally designed to offer such insights. We therefore argue that the methods could be enhanced to track such information and hence improve strategic purchasing. We also offer suggestions how this enhancement can be achieved.

Comme les pays à faible et moyen revenu se lancent dans des réformes de financement des soins de santé afin d'offrir une couverture maladie universelle, on constate un regain d'intérêt pour une répartition plus stratégique des fonds communs aux prestataires de soins de santé. Ces pays testent différentes méthodes de paiement des prestataires dans le but d'améliorer la stratégie d'achat. Ils ont donc besoin de données exhaustives sur les flux de financement entre ces prestataires de soins de santé et divers acquéreurs s'ils souhaitent prendre des décisions avisées dans ce domaine. La traçabilité du flux de financement est au cœur de plusieurs outils de suivi des ressources de santé, dont le Système des comptes de la santé et les enquêtes de suivi des dépenses publiques. Cette étude vise à déterminer si ces outils de suivi des ressources de santé génèrent le type d'information requis pour élaborer des stratégies d'achat adéquates, avec le Kenya en guise d'exemple. Notre analyse qualitative de trois comtés kényans démontre que différents acquéreurs publics, à savoir les autorités sanitaires des comtés et l'Agence nationale de l'assurance maladie, rémunèrent les établissements publics par le biais d'une série de méthodes de paiement. Certains de ces flux sont réglés en nature, tandis que d'autres sont des transferts financiers. La catégorie à laquelle appartiennent les flux ainsi que l'autonomie financière des établissements en termes de conservation et de dépense des fonds varient considérablement selon les comtés et les niveaux de soins. Le gouvernement mène systématiquement diverses activités de suivi des ressources de santé afin de mieux orienter la planification et la politique en la matière. Néanmoins, il manque toujours une source fiable de données exhaustives concernant le flux de financement des établissements publics car à l'origine, ces activités ne sont pas conçues pour livrer de telles observations. Nous affirmons dès lors que ces méthodes pourraient être optimisées pour récupérer ces informations et améliorer ainsi la stratégie d'achat. Nous formulons également des suggestions permettant de procéder à cette optimisation.

A medida que los países de ingresos bajos y medianos emprenden reformas de la financiación de la salud para lograr la cobertura sanitaria universal, se renueva el interés en que la asignación de fondos mancomunados a los proveedores de servicios de salud sea más estratégica. Para que las compras sean más estratégicas, los países están probando diferentes métodos de pago de los proveedores. Por lo tanto, necesitan datos completos sobre los flujos de financiación a los proveedores de servicios de salud de diferentes compradores para fundamentar la decisión sobre los métodos de pago. El seguimiento de los flujos de financiación es el objetivo de varias herramientas de seguimiento de los recursos sanitarios, incluidos el Sistema de Cuentas de Salud y las encuestas de seguimiento del gasto público. Este estudio explora si estas herramientas de seguimiento de recursos sanitarios generan el tipo de información necesaria para fundamentar las reformas de compras estratégicas, utilizando como ejemplo a Kenia. Nuestra evaluación cualitativa de tres condados de Kenia muestra que los diferentes compradores públicos, es decir, los departamentos de salud de los condados y la agencia nacional de seguro de salud, pagan a las instalaciones públicas a través de una variedad de métodos de pago. Algunos de estos flujos son en especie, mientras que otros son transferencias financieras. La naturaleza de los flujos y la autonomía financiera de los centros para retener y gastar los fondos varía considerablemente entre los condados y los niveles de atención. El gobierno lleva a cabo continuamente diferentes actividades de seguimiento de los recursos sanitarios para fundamentar las políticas y la planificación sanitaria. Sin embargo, sigue faltando una buena fuente de datos completos sobre el flujo de fondos a las instalaciones públicas, ya que estas actividades no se diseñaron originalmente para ofrecer este tipo de información. Por lo tanto, se argumenta que los métodos podrían mejorarse para hacer un seguimiento de dicha información y, en consecuencia, mejorar las compras estratégicas. También se ofrecen sugerencias sobre cómo se puede lograr esta mejora.

Purchasing reforms and tracking health resources, Kenya

As low- and middle-income countries undertake health financing reforms to achieve universal health coverage, there is renewed interest in making allocation of pooled funds to health-care providers more strategic. To make purchasing more strategic, countries are testing different provider payment methods. They therefore need comprehensive data on funding flows to health-care providers from different purchasers to inform decision on payment methods. Tracking funding flow is the focus of several health resource tracking tools including the System of Health Accounts and public expenditure tracking surveys. This study explores whether these health resource tracking tools generate the type of information needed to inform strategic purchasing reforms, using Kenya as an example. Our qualitative assessment of three counties in Kenya shows that different public purchasers, that is, county health departments and the national health insurance agency, pay public facilities through a variety of payment methods. Some of these flows are in-kind while others are financial transfers. The nature of flows and financial autonomy of facilities to retain and spend funds varies considerably across counties and levels of care. The government routinely undertakes different health resource tracking activities to inform health policy and planning. However, a good source for comprehensive data on the flow of funds to public facilities is still lacking, because these activities were not originally designed to offer such insights. We therefore argue that the methods could be enhanced to track such information and hence improve strategic purchasing. We also offer suggestions how this enhancement can be achieved