Tracking implementation and (un)intended consequences: A process evaluation of an innovative peripheral health facility financing mechanism in Kenya

  • Waweru E
  • Goodman C
  • Kedenge S
 et al. 
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In many African countries, user fees have failed to achieve intended access and quality of care im-provements. Subsequent user fee reduction or elimination policies have often been poorly planned, without alternative sources of income for facilities. We describe early implementation of an innova-tive national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are man-aged by health facility management committees (HFMCs) including community representatives. HSSF is therefore a finance mechanism with potential to increase access to funds for peripheral facili-ties, support user fee reduction and improve equity in access. We conducted a process evaluation of HSSF implementation based on a theory of change underpinning the intervention. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. We found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involve-ment; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; inter-actions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, na-tional reduction policies were still not being adhered to. Finance mechanisms can have a strong posi-tive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and en-sure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need. Process evaluations tracking (un)intended con-sequences of interventions can contribute to regional financing and decentralization debates.

Author-supplied keywords

  • Accountability
  • Africa
  • Community involvement
  • Decentralization
  • Peripheral facility financing
  • Quality of care
  • Relationships
  • User fee removal

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  • Evelyn WaweruCentre for Geographic Medicine Research Coast

  • Catherine Goodman

  • Sarah Kedenge

  • Benjamin Tsofa

  • Sassy Molyneux

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