Performance assessment of the county healthcare systems in Kenya: a mixed-methods analysis

Abstract

IntroductionA well performing public healthcare system is necessary for Kenya to continue progress towards universal health coverage (UHC). Identifying actionable measures to improve the performance of the public healthcare system is critical to progress towards UHC. We aimed to measure and compare the performance of Kenya’s public healthcare system at the county level and explore remediable drivers of poor healthcare system performance.MethodsUsing administrative data from fiscal year 2014/2015 through fiscal year 2017/2018, we measured the technical efficiency of 47 county-level public healthcare systems in Kenya using stochastic frontier analysis. We then regressed the technical efficiency measure against a set of explanatory variables to examine drivers of efficiency. Additionally, in selected counties, we analysed surveys and focus group discussions to qualitatively understand factors affecting performance.ResultsThe median technical efficiency of county public healthcare systems was 84% in fiscal year 2017/2018 (with an IQR of 79% to 90%). Across the four fiscal years of data, 27 out of the 47 Kenyan counties had a declining technical efficiency score. Our regression analysis indicated that impediments to the flow of funding—measured by the budget absorption rate which is the ratio between funds spent and funds released—were significantly related to poor healthcare system performance. Our analysis of interviews and surveys yielded a similar conclusion as nearly 50% of respondents indicated issues stemming from poor budget absorption were significant drivers of poor healthcare system performance.ConclusionPublic healthcare systems at the county-level in Kenya general performed well; however, addressing delays in the flow of funding is a concrete step to improve healthcare system performance. As Kenya—and other countries—provides additional funding to meet their UHC goals, establishing a strong and robust public financial management system is critical to ensure that the benefits of UHC are realised.

Analysing the Efficiency of National and Sub-national health systems - A Systematic Review of Literature

“…Quantitative approaches were used to measure the level and determinants of e ciency. Qualitative approaches were used to examine study participants' perceptions about the objectives of the health system [41,45] and existence and nature of health system ine ciency and its determinants [41,[45][46][47][48]. Beyond identi cation, qualitative approaches provided explanations of the relationship between identi ed determinants and health system e ciency [36,48,49].…”

“…Of the papers that used panel data, 36(67%) used the Malmquist productivity index (MPI) approach to measure e ciency changes over time, while 18 (33%) included time as a covariate in a regression analysis. Four publications (2%) employed qualitative approaches [36,46,[53][54][55] while 2 studies (2%) used a mixed methods approach by combining both qualitative and quantitative methods [47,49].…”

“…Total health expenditure as a share of GDP was positively associated with the technical e ciency of health systems [38,42,65,99]. The role of availability of funds was also highlighted in Kenya [47,48]. This was thought to be because greater healthcare spending was essential in improving health outcomes [65].…”

“…Public nance management arrangements also in uenced health system e ciency. Enhanced capacity to execute budgets, ow of funds directly to providers, timeliness of funds disbursements to local authorities and health facilities, the exibility of budgets, and the autonomy of local authorities and health facilities over resources enhanced e ciency [45,47,48].…”

“…Procurement ine ciencies were also identi ed. This included fragmented procurement of health commodities, high procurement prices, and supply chain challenges leading to delays in deliveries and stock-outs, and procurement corruption [45,47,53]. Verhoeven et al (2007) found that high spending on pharmaceuticals was associated with lower health system e ciency.…”