Case studies

for

Health Systems and Policy Analysis

Case Study on Health Systems GOVERNANCE AND FINANCING

Health Facility Committees and Financial Management Structures in Kenya - Participants’ Guide


The development of sustained African health policy and systems research and teaching capacity requires the consolidation and strengthening of relevant research and educational programmes as well as the development of stronger engagement between the policy and research communities. The Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA) will address both of these issues over the period 2011 - 2015. CHEPSAA’s goal is to extend sustainable African capacity to produce and use high quality health policy and systems research by harnessing synergies among a Consortium of African and European universities with relevant expertise. This goal will be reached through CHEPSAA’s five work packages:

1.  assessing the capacity development needs of the African members and national policy networks;

2.  supporting the development of African researchers and educators;

3.  strengthening courses of relevance to health policy and systems research and analysis;

4.  strengthening networking among the health policy and systems education, research and policy communities and strengthening the process of getting research into policy and practice;

5.  project management and knowledge management.


The CHEPSAA project is led by Lucy Gilson (Professor: University of Cape Town & London School of Hygiene and Tropical Medicine).

PARTNERS

·  Health Policy & Systems Programme, the Health Economics Unit, University of Cape Town, South Africa

·  School of Public Health, University of the Western Cape, South Africa

·  Centre for Health Policy, University of the Witwatersrand, South Africa

·  Institute of Development Studies, University of Dar es Salaam, Tanzania

·  School of Public Health, University of Ghana, Legon, Ghana

·  Tropical Institute of Community Health, Great Lakes University of Kisumu, Kenya

·  College of Medicine, University of Nigeria Enugu, Nigeria

·  London School of Hygiene & Tropical Medicine, United Kingdom

·  Nuffield Centre for International Health and Development, University of Leeds, United Kingdom

·  Karolinska Institutet, Sweden

·  Swiss Tropical and Public Health Institute, University of Basel, Switzerland

CHEPSAA WEBSITE

www.hpsa-africa.org

Acknowledgements

An acknowledgement is given to all CHEPSAA partners who contributed to the course development process.

Suggested citation

CHEPSAA. (2014). Introduction to Complex Health Systems: Case Study materials. CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org

/ This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC. /

A Case Study on Health Systems Governance and Financing:

Health facility committees and financial management structures in Kenya

There are a number of goals or objectives we would like you to achieve through doing this case study, as listed below:

Learning Objectives of the case study

·  Identify the key agents in the case and describe their relationships within the health system, as part of the socially constructed nature of the health system.

·  Identify the key contextual features of this case

·  Analyse the mindsets, interests, power and agency of key agents in the situation.

·  Analyse how the introduction of Direct Facility Funding impacted on the existing relationships among agents, and is itself affected by those reactions.

·  Identify intended and unintended consequences of the new policy.

·  Suggest alternative strategies that could have been used to strengthen the intervention, using systems thinking and taking into consideration both hard and soft aspects of the health system.

·  Plan and deliver a group presentation, using effective groupwork and communication skills.

Tasks

After reading the case study narrative (pages 8 - 13 of this handout), do tasks A – D below in your small groups, in preparation for a 20 minute presentation about the case study which should cover the following:

A. Overview of the case (5 minute presentation) – to include:

1.  Key features of the case – Draw a flow diagram showing the main drivers and events of the case and how each stage had consequences, some of which were not intended.

2.  Context of the case study - Complete the context analysis form on page 4 identifying the key features of this particular case and how they have contributed to the situation.

B. Identify the hardware and software issues and elements which are most important in shaping this case, using guidance from Aragon’s framework below, and explain how they are linked and interact. (5 minute presentation)


C. Stakeholder analysis. Identify the key agents in the case and, situating them in the time when the DFF scheme had just been introduces, map these in diagram 1, (you can also use Form 1 on page 5 below to help your analysis) according to their levels of commitment and power to impact on successful implementation of the change. Draw lines between agents who have a close relationship with each other (e.g. through flow of money or information, lines of command or support). Consider how their position on the map changed over time, and be prepared to explain this, as well as agents’ mindsets and levels of power, and how agents are related to each other. (5 minute presentation)

D. Leading and managing change. Put yourselves in the position of a Facility Management Nurse (FMN) in the case. You are well-acquainted with the challenges of implementing the intervention and are looking for support for the changes. As this facility-level leader, think about how you can improve already quite successful implementation and act against the practice of continuing to charge high user fees. Using the concepts and frameworks you have been introduced to in the course, above and in the session 7 lecture on ‘Leadership of change in health systems’, design 3 strategies to increase other agents’ understanding and buy-in – particularly HFC members and communities. These could include small wins. In developing strategies also think of the ideas raised in the Duncan Green video. (5 minute presentation)

On the next two pages are templates you can use for your Context and Stakeholder Analysis.

In preparing your presentation consider the following:

·  Consider your audience, and design the presentation so that the level, language and content are appropriate for them;

·  Make sure you have covered all the necessary/important information;

·  Organise your points/ideas in a logically and clearly structured way;

·  Introduce the presentation with an attention catching question or comment, and a brief preview of the content;

·  The body of the presentation should have clear main and sub-points;

·  Keep to the allocated time (if possible ask a colleague to check the timing for you);

·  Speak clearly and not too fast;

·  Conclude the presentation with a brief re-statement of the main points or a summarising comment.

You will use these criteria for assessing the group presentations:

Assessment criteria
The overview of the case is clear and succinct and gives a clear image of what the case is about.
The hardware and software issues at play in the case, and their relationship, are clearly explained.
The roles of actors, their mindsets, interests and power are presented and explained convincingly.
The suggested strategies for leading change are well motivated.
Delivery of the presentation (visual and oral) is clear, using appropriate pace and level, and content is coherently and logically structured.

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CHEPSAA case studies for health policy and systems analysis

Contextual feature / Specific issues relevant to this experience (remember not all issues might be relevant to this case) / Impact of these issues on actors (name these) and the case, and implications for policy implementation
Micro context
organisational climate & culture
other policies
organisational capacity
interpersonal factors
Macro context
social & political pressures & interests
historical & socio-cultural context
economic conditions & policy
international context
environmental factors
Form 1. Unpacking agent behavioural drivers and power
AGENT / Mindsets, values and interests / Forms and level of power to influence implementation
What are the core elements of the agent’s ‘mindset’ (beliefs, values driving behaviour in general?) / Given the elements identified in column 1, is actor’s response to the change likely to be committed, compliant, indifferent, resistant, or hostile? / What forms of power can the agent mobilise to support his/her actions around the new policies? / What power limits does the actor face in taking action around the new policies?

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CHEPSAA case studies for health policy and systems analysis

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CHEPSAA case studies for health policy and systems analysis

Health Facility Committees and financial management: A Kenyan case study

Narrative

Background

This case study examines the implementation of two policies in Kenya aimed at health system strengthening. The first is Health Facility Committees (HFC’s) - an approach to broadening community participation in public health service delivery; and the second Direct Facility Funding (DFF) - a mechanism for transferring health funding to the periphery of the health system.

From the 1980’s, various approaches were taken by Kenyan authorities towards reforming the health system, with the aim of leveraging improvement in utilisation and quality of care of health services. Community participation and decentralisation were important drivers of these reforms.

Below is a timeline showing the development of some relevant reforms over the period covered in the case study:

1980’s / Introduction of user fees to provide more revenue and therefore better health services in public health facilities;
Introduction of Health Facility Committees with responsibility for disbursing most of the user fee revenue.
1998 / Health Facility Committees (HFC) officially established, with prescribed roles and responsibilities, supported by funds from the Ministry of Health and the Danish International Development Agency (DANIDA)
2004 / User fees reduced to widen access to public health services; however this reduced facilities’ revenue and therefore their capacity for providing services.
2004 / Direct Facility Funding (DFF) scheme introduced to channel more revenue from central government to health facilities, to make up for loss of income from reduction of user fees. The scheme was piloted in Coast Province.
2005 / Role of HFC’s expanded to include management of facility budgets under the DFF scheme
2007 - 2009 / Government regulation regarding roles and functions, and composition of HFC’s
2010 - 2012 / National roll-out of HFC’s for public health centres and dispensaries, based on perceived success of pilot

Health Facility Committees

The Kenyan government officially established Health Facility Committees in 1998, as a contribution towards building community accountability in public health.

Their roles were defined as follows:

Roles of the HFC
1. To oversee the general operations and management of the health facility
2. To advise the community on matters related to the promotion of health services
3. To represent and articulate community interests on matters pertaining to health in local development forums
4. To facilitate a feedback process to the community pertaining to the operations and management of the health facility
5. To implement community decisions pertaining to their own health
6. To mobilise community resources towards the development of health services within the area
Powers of the HFC
1. The committee shall have the authority to raise funds from within itself, the community or from donors and other well-wishers for the purpose of financing the operations and maintenance of the facility
2. The committee shall have authority to hire and fire subordinate staff employed by itself in the health facility
3. The committee shall oversee the development and expansion and maintenance of the physical facilities within their respective area

Source: Managing a Health Facility: A Handbook for Committee Members and Facility Staff. Ministry of Health & Aga Khan Health Service, Kenya, Second Edition, 2005 [13]

Committee members included the health worker in-charge of the health facility as secretary and between 8 and 18 community members. The chair and the treasurer were chosen from the community members. Most of the latter were farmers, though some were professionals such as teachers, and a few were community health workers. A few committees had Area Chiefs and Councilors as members by virtue of their official role. All committees had at least one female member as required by DFF guidelines.

All HFCs had a constitution which outlined rules and codes of conduct regulating committee functioning, such as frequency of meetings.

HFC’s were to be supported and strengthened by management training provided by the Ministry of Health and DANIDA Health Services project. In 2005 the roles of the HFC’s were expanded to include management of budgets and funds under the DFF scheme.

Direct Facility Funding (DFF) scheme

Prior to 2004 primary health care services had two sources of funding: resources for infrastructure, drugs, medical supplies and staffing had been supplied by the Ministry of Health (later called the Ministry of Public Health and Sanitation), but these had often not ‘trickled down’ to facilities as intended: in some cases barely 30% of funding made it to small facilities. The only other income available to health facilities was that gathered from user fees and other income generating schemes such as the sale of mosquito nets. However, there had been pressure for the abolition or reduction of health facility user fees, as these had been seen as a barrier to health access for the poor.

In 2004, Kenya removed high and variable user fees for health facilities, replacing them with flat rate fees of KES 10 (approximately US$ .15) at dispensaries, and KES 20 (approximately US$ .30) at health centres.

In response to concerns that these lower fees limited the money available to health facilities for daily expenditures, the Kenyan Government and the Danish International Development Agency (DANIDA) piloted an innovative scheme of directly funding health facilities in one province in Kenya (Coast Province): Direct Facility Funding (DFF).

With direct facility funding, health facilities receive money directly into their bank account. All health facilities with qualified staff were eligible for DFF, which was to be allocated according to a set of criteria based on workload and facility type. Another key provision for participation in the DFF scheme was that facilities comply with the national policy on reduced user fees.