Direct facility funding as a response to user fee reduction: implementation and perceived impact among Kenyan health centres and dispensaries

Abstract

There is increasing pressure for reduction of user fees, but this can have adverse effects by decreasing facility-level funds. To address this, direct facility funding (DFF) was piloted in Coast Province, Kenya, with health facility committees (HFCs) responsible for managing the funds. We evaluated the implementation and perceived impact 2.5 years after DFF introduction.Quantitative data collection at 30 public health centres and dispensaries included a structured interview with the in-charge, record reviews and exit interviews. In addition, in-depth interviews were conducted with the in-charge and HFC members at 12 facilities, and with district staff and other stakeholders.DFF procedures were well established: HFCs met regularly and accounting procedures were broadly followed. DFF made an important contribution to facility cash income, accounting for 47% in health centres and 62% in dispensaries. The main items of expenditure were wages for support staff (32%), travel (21%), and construction and maintenance (18%). DFF was perceived to have a highly positive impact through funding support staff such as cleaners and patient attendants, outreach activities, renovations, patient referrals and increasing HFC activity. This was perceived to have improved health worker motivation, utilization and quality of care.A number of problems were identified. HFC training was reportedly inadequate, and no DFF documentation was available at facility level, leading to confusion. Charging user fees above those specified in the national policy remained common, and understanding of DFF among the broader community was very limited. Finally, relationships between HFCs and health workers were sometimes characterized by mistrust and resentment.Relatively small increases in funding may significantly affect facility performance when the funds are managed at the periphery. Kenya plans to scale up DFF nationwide. Our findings indicate this is warranted, but should include improved training and documentation, greater emphasis on community engagement, and insistence on user fee adherence.

Are Health Facility Management Committees in Kenya ready to implement financial management tasks: findings from a nationally representative survey

“…These dimensions of HFMC functioning were chosen based on guidelines (Table 1), findings of the Coast pilot of direct facility funding [6], and characteristics of HFMCs that could be measured quantitatively in a nationally representative survey. Questions were structured using three main approaches, with specific questions and options refined through careful piloting in two districts a .…”

Health facility committees and facility management - exploring the nature and depth of their roles in Coast Province, Kenya

“…Details of the implementation and effects of DFF in general are described elsewhere [16]. This paper assesses the nature and depth of managerial engagement of HFCs at the facility level, and how this has contributed to community accountability in the context of the DFF financing mechanism.…”

The community is just a small circle: citizen participation in the free maternal and child healthcare programme of Enugu State, Nigeria

“…In contrast, the HFCs are involved in a provider payment system for free healthcare in Burkina Faso and Kenya [28,29]. As purchasing is an important strategic lever in UHC, the HFCs could facilitate the registration of eligible users with their primary providers, endorse claims forms and participate in managing facility FMCHP accounts.…”

“…As purchasing is an important strategic lever in UHC, the HFCs could facilitate the registration of eligible users with their primary providers, endorse claims forms and participate in managing facility FMCHP accounts. These roles of the HFCs in service provision and provider payment not only needed to be explicitly written in the FMCHP policy, but also required, as Anwari et al [52] observed, consistent implementation through stakeholder engagement, consensus orientation and information sharing with providers and communities, and training to avoid experiences in Kenya where the HFCs were inadequately trained to manage direct facility funding [29]. …”

“…Health facilities with strong, supportive and skilled health committees enhanced implementation of free healthcare policy in Nepal [27]. The use of HFCs in financial management of free healthcare policies in health centres in Burkina Faso and Kenya increased transparency in the fund management [28,29]. Although, Onwujekwe et al [23] found a lack of community involvement in a free maternal and child healthcare policy in Nigeria, the study did not provide evidence of how the HFCs influenced the health financing functions (revenue generation, management of FMCHP fund and purchasing) and responsiveness of service providers.…”