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Tracking implementation and (un)intendedconsequences of peripheral health facility financing
mechanisms in Kenya
P4P workshop – Evelyn Waweru Nov 2015
POLICY PROCESSCONTEXT ACTORS
Outline
Background: Kenyan health sector policy reforms
What is DFF and HSSF and how its supposed to work
Experiences with implementation of HSSF
Current proposal and way forward
NB: Peripheral health facilities = public health centres and dispensaries
Health Sector Services Fund (HSSF)
Background: need to improve the efficiency, quality, equity and sustainability of primary care provision in developing countries and guided by global debates on UHC, decentralisation and community participation.
An innovative GOK scheme to:- Disburse funds directly to peripheral facilities- Empower local communities through Health Facility Management
Committees (HFMCs)
Overall goal:- Generate sufficient resources for providing curative, preventive and
promotive services - Reduce user fees paid- Account for the resources in an efficient and transparent manner
Parliament
Treasury
Central Bank of Kenya
HSSF Account
HFMC (Facility
Commercial Bank
Account)
FBO Facilities
/Private Sector
Commercial Bank
Accounts
Donors
Minister
MOPHS
PS
MOPHS
(HSSF Secretariat)
National Health Services
Committee
DHMT Commercial
Bank Account
Disbursement of funds
Authority to Incur Expenditure (AIE)
Funds distribution schedules
District Treasury
PHMT Commercial
Bank Account
Ministry of Finance
HSSF Budget estimates
Budget Approval
HSSF Secretariat
Commercial Bank
Account
Source: Guidelines on Financial Management for the Health Sector Services Fund
HSSF Funding and Disbursement Pathways
Funds transfer
HSSF Funds cover: Facility operations and maintenance; should not cover: Drugs, personal expenses and non-voted items
Planning: Involve stakeholders (HFMC) in making AWPs and QIPs which then translate to facility and sub-county budgets
Funds managed by the HFMC:, according to financial guidelines approved by MOH
Spending: only on receipt of an Authority to Incur Expenditure (AIE) from national level
Accounting and financial management: facility monthly reports counter-checked by county accountant
Supportive supervision: DHMT and (CBAs) hired specifically
How should HSSF work
Experiences with HSSF implementation
Key research findings Coast pilot: small increases in the
funding available for the day to day running of facilities greatly improved facility functioning and perceived quality of care
Most facilities were ready to receive HSSF: - Bank account - Functioning HFMC- Some training – more emphasis
on financial management
Associations between health facility characteristics and the poverty level of the facility location- No major inequalities in inputs,
there was need for an overall increase in inputs:
Health Policy and Planning
0.9% of total ‘on-budget’ health sector budget
HSSF Interim process evaluation: Findings
KSH 112,000 (1,339 USD) per health centres
KSH 27,500 (327 USD) per dispensaries
KSH 131,500 (1,565 USD) per DHMTs
Per quarter
Perceived positive impacts Funds were reaching facilities Visible improvements in facilities More reported outreach activities Improved perceived quality of care, staff motivation and
patient satisfaction
“of course the quality of care has improved; initially if you didn’t have gloves you would tell a client- sorry we can’t help you” (Health Centre In-charge)
Participation, transparency and accountability- Active involvement of community members through HFMCs - Greater transparency and improved oversight of user fee
revenues
HSSF Implementation Challenges and ways of fixing them
Challenges in financing
Delays in receiving funds: AIEs were also fixed“a straight jacket on HSSF because they had given us sort of an AIE …it has to be utilized on the item which is indicated ”(HFMC member) – fixed by annual AIEs; working on flow of funds
Inadequate level of funds – working on increasing county buy in and discussions with donors on a pooling system
Compensation for removed user fees – flat rate, RAC and utilisation
Low allowances for HFMCs “peanuts” no incentives for staff – mixed opinions
Different donor opinions“the lack of the involvement of the district treasury is the Achilles heel of HSSF” (National KI) – ongoing dialogue with donors and the Council of Governors
Supportive supervision and accountability
Lack of training on financial management
Lack of facilitation and systematic M&E
Understanding of roles and responsibilities
Overworked CBAs
Reluctant in-charges“Kwamad with terror”(National KI)
[At the DHMT level] you are actually doing an accountant’s work and you’ve never trained for it ...you can be taught for 3 days or 5 days and you think you get it, [but] you keep on forgetting … (DHMT member).
Unintended consequences
Complex reporting and documentation: time consuming – priority documents to submit to CBA
Difficulties in adhering to the rules of spending: flexibility – need for clear and comprehensive guidelines
Bypassing the district treasury– They (CBAs) are not linked with the District Treasury for technical
support and integration within DHMTs remains weak and accountants are not always included during supervision visits to facilities’ (2013 Aide Memoire). – still an issue with the county treasury now having more decision power over county spending
Relationship problems between key stakeholders– Diff views on how HSSF should work after devolution –
compounded by devolution and politicians influence on the HFMC
Items required for financial management of HSSF at facility level
(Source: Managing the HSSF – An Operations Guide)
Guidelines and Reference Documents
• Managing the HSSF – An Operations Guide
• Guidelines on Financial Management for HSSF
• Chart of Accounts
Registers / Books to be completed
• Memorandum Vote Book (MVB)
• Receipt Book
• Facility Service Register (FSR)
• Cash Book
• Cheque Book Register
• Fixed Assets Register
• Imprest Register
• Consumables Stock Register
• Store Register
• Counter Receipt Book Register
Other items
• Cheque book
Forms / Vouchers
• Receipt Vouchers (F017)
• Payment Vouchers (F021)
• Travel Imprest Form (F022)
• Local Purchase Orders (LPO)
• Local Service Orders (LSO)
• Request for Quotations (RFQ)
• Stock Cards for all items in stores
• Imprest Warrants
• Bank Reconciliation forms (F030)
• Counter Requisition and Issue Vouchers (S11)
• Counter Receipt Vouchers (S13)
• Handover Forms
• Monthly Service Delivery Report Forms (MOH105)
• Monthly Financial Report forms (MFR)
• Monthly Expenditure Report forms (MER)
• Quarterly Financial Report forms (QFR)
Only financial! There are numerous other daily registers and monthly reports to fill
Re-organisation of the Kenyan health system!
• Devolution: 47 new semi-autonomous counties (control decisions)
• User fee “removal” + free maternal (P. Directive)
• Debate on future HSSF design
o funds be controlled at county of national level?
o integrated into standard government financial systems? Role of insurance?
o performance related?
Conceptual framework : How HSSF is to function in a devolved health system context
1.
Use of Funds
2.
Access rules
3.
Human resource
4.
Governance /
accountability
5.
Resource Allocation
PBF?
Context: Peripheral facility funding regulatory/legislative frameworks, policies and priorities of national
government, international organisations, and county government
Consequences for peripheral health facilities
Facility income
& expenditure
Adherence to
user fee
regulationsInternal & community
accountability
Health worker
motivation
Perceived
Quality of
care
Utilisation
5 key decision making domains: theory and practice
Way forward? Different counties different health system structures and
varying levels of control of funds New financing mechanisms:
– Reimbursements for user fees (flat rate, with talks of linking amounts to facility utilisation)
– Reimbursements for free maternity health services (2500 per delivery)
– DANIDA funds (last financial year)– NHIF?– OBA: selected counties (complementary to FMS but with staff
incentives)– PBF: pilot
Data analysis and feedback – research to policy, implementation research?
Next steps: PBF checklist?
Knowledge Gaps around HSSF
• Continuity, transition period, future politics
• Flexibility in designo funds be controlled at county of national level?
o integrated into standard government financial systems? Role of insurance?
o performance related?
• Best methods for evaluation – and balancing mixed methods
– selection of indicators of performance
Acknowledgements Supervisors: Drs Sassy
Molyneux, Catherine Goodman
Co-investigators:Benjamin Tsofa, Mary Nyikuri, Jacinta Nzinga, Edwine Barasa, Jane Chuma, Anisa Omar, Timothy Malingi
Research participants