Development assistance for health programmes is often characterised as donor-led models with minimal country ownership and limited sustainability. This article presents new ways for low-income and middle-income countries to gain more control of their development assistance programming as they move towards universal health coverage (UHC). We base our findings on the experience of the African Collaborative for Health Financing Solutions (ACS), an innovative US Agency for International Development-funded project. The ACS project stems from the premise that the global health community can more effectively support UHC processes in countries if development partners change three long-standing paradigms: (1) time-limited projects to enhancing long-lasting processes, (2) fly-in/fly-out development support to leveraging and strengthening local and regional expertise and (3) static knowledge creation to supporting practical and co-developed resources that enhance learning and capture implementation experience. We assume that development partners can facilitate progress towards UHC if interventions follow five action steps, including (1) align to country demand, (2) provide evidence-based and tailored health financing technical support, (3) respond to knowledge and learnings throughout activity design and implementation, (4) foster multi-stakeholder collaboration and ownership and (5) strengthen accountability mechanisms. Since 2017, the ACS project has applied these five action steps in its implementing countries, including Benin, Namibia and Uganda. This article shares with the global health community preliminary achievements of implementing a unique, challenging but promising experience.

Policies as they are written often mask the power relations behind their creation (Hull, 2008). As a result, not only are policies that appear neat on the page frequently messy in their implementation on the ground, but the messiness of implementation, and implementation science, often brings these hidden power relations to light. In this paper, we examine the process by which different data sources were generated within a programme meant to increase access to quality private healthcare for the poorest populations in Kenya, how these sources were brought and analyzed together to examine gender bias in the large-scale rollout of Kenya’s National Hospital Insurance Fund (NHIF) beyond public hospitals and civil service employees, and how these findings ultimately were developed in real time to feed into the NHIF reform process. We point to the ways in which data generated for implementation science purposes and without a specific focus on gender were analyzed with a policy implementation analysis lens to look at gender issues at the policy level, and pay particular attention to the role that the ongoing close partnership between the evaluators and implementers played in allowing the teams to develop and turn findings around on short timelines. In conclusion, we discuss possibilities for programme evaluators and implementers to generate new data and feed routine monitoring data into policy reform processes to create a health policy environment that serves patients more effectively and equitably. Implementation science is generally focused on programmatic improvement; the experiences in Kenya make clear that it can, and should, also be considered for policy improvement.

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.