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Implementation Research: Taking Results Based Financing
from scheme to system
Scaling up Performance-Based Financing in Healthcare in a
Devolved Governance System: Experiences From Kenya.
Research Report [Kenya]
ii
Acknowledgements
This work was supported by the Aliance for Health Policy and Systems
Research, as part of a multi country study examining performance based
financing (PBF). We would like to thank the research informants who
included the various representatives of partners, the donors, the officials
at the Kenyan Ministry of Health headquarters and the key officials of the
department of health in the various counties. Particular thanks go to the
Alliance for Health Policy and Systems Research within the World Health
Organization (WHO) and technical support team for this multicountry
study at the Institute of Tropical Medicine (ITM) in Antwerp in Belgium.
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Table of Contents
Acknowledgements ...........................................................................................................................ii
List of Tables ...................................................................................................................................... vi
Acronyms ............................................................................................................................................ vii
Executive Summary ......................................................................................................................... 1
Background ......................................................................................................................................... 1
Methodology ....................................................................................................................................... 2
Key Findings ....................................................................................................................................... 2
Recommendations ............................................................................................................................ 5
1.0 Introduction ................................................................................................................................ 6
2.0 Background ................................................................................................................................. 8
2.1 The Kenyan Context ................................................................................................................ 8
2.1.1 Health Financing Policy Context .................................................................................. 9
2.1.2 The Performance-Based Financing Intervention ................................................... 9
2.2 Study objectives ...................................................................................................................... 11
2.2.1 General Objective ........................................................................................................... 11
Objectives .......................................................................................................................................... 11
2.2.2 Specific objectives .......................................................................................................... 11
3.0 Methodology ............................................................................................................................. 12
3.1 Conceptual framework (Further reading and adapting to the current study). 12
3.2 Research Questions ........................................................................................................... 14
3.3 Research Design .................................................................................................................. 14
3.3.1 Study Design .................................................................................................................... 14
3.3.2 Instruments ...................................................................................................................... 14
3.3.3 Sample ................................................................................................................................ 16
3.3.4 Data Collection ................................................................................................................. 16
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3.3.5 Data Analysis .................................................................................................................... 18
3.3.6 Study Limitations ............................................................................................................ 19
4.0 Study Findings ......................................................................................................................... 20
4.1 The dynamics of the process, context, content and actors that enable or
hinder the scaling up decision and/or implementation of the PBF .............................. 20
Introduction ...................................................................................................................................... 20
4.1.1 The process of scaling up of Performance Based Financing in Kenya: .......... 25
i) Ideas and Knowledge ............................................................................................................ 25
ii) Country ownership of PBF and integration into health system ........................... 27
a) Development of the scale up manual ........................................................................ 27
c) Orientation of lessons learnt from Samburu pilot .................................................... 30
4.1.2 Context ................................................................................................................................... 35
4.1.2.1 Macro-contextual issues ........................................................................................... 35
4.1.3 Actors in scaling up of Performance-Based-Financing (PBF) in Kenya .......... 38
Introduction ...................................................................................................................................... 38
i) Development Partners .......................................................................................................... 39
ii) National Level Actors ........................................................................................................... 42
4.2 Effects of Institutional Re-arrangements Under the Devolved Governance on
PBF Scale up in Kenya .................................................................................................................. 46
4.2.1) Introduction ......................................................................................................................... 46
4.2.2) Devolution as an enabler to scaling up of PBF ...................................................... 46
a) Localised decision-making process ................................................................................ 47
b) Improvement in Infrastructure ........................................................................................ 49
c) Strengthened Accountability ............................................................................................. 51
d) Activated Community Health Strategy ......................................................................... 53
4.2.3) Devolution as a barrier to scaling up of PBF ...................................................... 57
b) Anticipated problems of drug and supplies stock out ......................................... 57
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4.3 Political Economy considerations of the scaling up of PBF ..................................... 60
4.3.1 Introduction ...................................................................................................................... 60
4.3.2 The need to obtain political buy-in .......................................................................... 61
4.3.3 Effects of political aspirations on PBF scale up ................................................... 64
5.0 DISCUSSIONS .......................................................................................................................... 65
6.0 Conclusions and Recommendations ................................................................................ 75
6.1 Conclusions ............................................................................................................................... 75
6.2 Recommendations .................................................................................................................. 78
6.2.1 Recommendation for further research ............................................................... 79
7.0 References ................................................................................................................................. 80
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List of Tables
Table 1: Quantity Indicators for the PBF scaling upError! Bookmark not
defined.
Table 2: Thirteen (13) Areas for Quality AssessmentError! Bookmark
not defined.
vii
Acronyms
AIDS –Aquired Immuned Deficiency Syndrom
AMREF –African Medical Research Foundation
ASAL- Arid and Semi-Arid Lands
CDoH –County Department of Health
CEC –County Executive Officer
CHVs –Community Health Volunteers
CHRIO –County Health Records Information Officer
CIDP –County Integrated Development Plan
CPHN –County Public Health Nurse
CPHO –County Public Health Officer
DHIS –District Health Information System
DHMT- District Health Management Team
HFMC- Health Facility Management Committee
HIV –Human Immunodeficiency Virus
HPSR –Health Policy and Systems Research
ITM –Institute of Tropical Medicine
KEMSA- Kenya Medical Supplies Agency
KHP –Kenya Health Policy
MCA –Member of County Assembly
MCH- Maternal and Child Health
MOH –Ministry of Health
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MoU –Memorandum of Understanding
OBA –Output Based Approaches
PBF –Performance Based Financing
PHMT- Provincial Health Management Team
RBF- Results Based Financing
ToT- Trainers of Trainers
UNFPA –United Nations Fund For Population Activities
UNICEF- United Nations Children’s Fund
USAID- United Stated Aid for International Development
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Executive Summary
Background
Kenyan health system like others in sub-Saharan Africa faces challenges
of poor coverage, lack of infrastructure, equipment, poor retention and
unmotivated health workers. These challenges have contributed to poor
access to and utilization of basic health services notably by the vulnerable
groups, thus, escalating levels of inequities. Current efforts to address the
glaring gap in access to basic health services by populations living in Arid
and Semi-Arid Lands (ASAL) regions include attempts to pilot and scale up
Performance-Based Financing (PBF). At the same time, Kenya is
implementing a devolved system of governance that has led to
institutional reforms in various sectors including the health sector. This
study aimed at documenting and analyzing the development (scaling up)
process of PBF in ASAL regions in Kenya from July 2011 to September
2015 and draw lessons for further scaling up and sustaining such
initiative, nationally and internationally. The study further aimed at
analyzing how the re-arrangements of the health care institutions within
the newly devolved system influenced the scaling up process. In addition
the study also aimed at analysing how the lessons learnt in the Samburu
pilot have been integrated in the scale-up process as well as to explain the
political economy considerations that are influencing the scaling up of PBF
in Kenya.
2
Methodology
The study design was both retrospective and prospective aimed at
collecting qualitative data on the process of conceptualizing, designing and
implementing the PBF pilot from 2011 to the stage of scaling up as of May
2015.
The methods of data collection included desk review and key informant
interviews with selected representatives of various institutions that were
either involved in the piloting of PBF in Samburu or are currently involved
in the scaling up of PBF in Kenya. The potential study participants were
identified through a thorough process of stakeholders mapping,
thereafter, they were selected purposively based on their institutions’
participation in PBF scaling up in Kenya. Telephone contact was made with
the identified officers and they were later approached directly for
interview. A total of 22 interviews were conducted with various
stakeholders. The discussions were tape-recorded in English and then
transcribed into Word format. The transcribed texts were then transferred
to NVIVO 10 analysis software and analysed. Following coding, a full list of
themes was made available for categorization within a hierarchical
framework of main and sub-themes.
Key Findings
The process of scaling up PBF in Kenya from a pilot scheme to a
healthcare system has been influenced by several factors. These factors
include; the international debate and efforts towards Universal Health
3
Coverage, the need to meet Millennium Development Goals related to
improvement of Maternal and Child Health indicators and prevention of
HIV transmission from the mothers to the child through PMTCT programs.
Further efforts at the International scene to enhance equity in access to
health services for the poor and vulnerable populations also influenced
piloting and eventual scaling up of performance-based financing in Kenya.
Furthermore, there was a need to pilot and eventually scale up PBF as a
mechanism to incentivise the already highly trained healthcare workforce
in Kenya. The local context that has informed the process of piloting PBF
has included; the earlier social protection approaches to the expansion of
access to primary and day secondary education through direct transfers to
schools which had been supported to open their own accounts. This was
followed by the Direct Facility Funding within the Healthcare in which all
health facilities opened their own accounts through which the donors
channelled funds like was the case with the Health Sector Services Fund.
The experiences and outcomes of these direct cash transfers to the
schools and health facilities as well as the lessons learnt from the piloting
of PBF in Samburu central have laid the basis for scaling up PBF in Kenya.
Difficulties in verification of the payments has been identified as one of the
most difficult task in the implementation process of PBF based on the
experiences from Samburu pilot. The difficulties in verification and the fact
that there are several interventions targeting improvements in the same
indicators as PBF has raised doubts among some actors as to the cost-
effectiveness of the PBF program in relation to other interventions aimed
at improving the overall health system performance. Furthermore, there is
evidence that health facilities management committees which had PBF and
other interventions used funds to incentivise pregnant women to attend
Ante Natal Clinics and deliver in the hospitals. Such additional funds
received by the health facilities were used to conduct community outreach
programs in partnership with Community Health Workers thus increasing
the visibility, access and utilization of health services earmarked as
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indicators under the piloting of performance-based-financing within such
facilities as compared to facilities that only incentivised health workers.
The institutional arrangements under the devolved governance and
particularly under the devolved health system has more enabling factors
to the scaling up of PBF in Kenya as compared to identified barriers.
Enabling factors include; the fact that decisions to allocate resources and
prioritize have been decentralised to the local political class and other
actors at the county governments. These localised decisions have
contributed to improvement in infrastructure within health facilities and
enhanced accountability in terms of decisions made regarding allocation of
resources and human resource management. Enhanced human resource
management has eliminated high rates of staff abseenteeism. In addition,
devolution has activated the community health units which had remained
inactive due to lack of funding from the national governments. It is
anticipated that these factors have created an enabling environment for
the scaling up of PBF.. On the other hand, barriers to PBF scaling up have
been identified as; lack of an intergovernmental coordinating mechanism
because certain dockets such as social protection and the national health
insurance have not been devolved and are likely to create complications
yet they have a direct relationship with the attainment of PBF indicators.
Another barrier to PBF scaling up has been identified as anticipated drugs
and other supplies stock out, particularly the vaccines and HIV testing kits
that most stakeholders have complained that the political establishment at
the county levels are not ready to spend resources in what are known as
products of national goods. The informants argued that the statistics that
emanate from HIV and AIDS prevention and immunization services do not
provide a platform for political campaigns as compared to investing funds
in projects and other routine drugs in the health facilities that are visible
to the local voters.
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Political actors have significant influence in the integration of PBF in the
healthcare financing system at the county level through approvals in the
newly established county assemblies. However, this can only be achieved
if the initial political buy-in is achieved at the beginning of the design and
implementation of PBF program. These approvals are done through the
Annual Health Plans and the County Integrated Development Plans.
Recommendations
1. There is a need to address the doubts emerging from the difficulties
associated with verification of the payments of the PBF incentives.
2. There is a need to ensure that the cost effectiveness of PBF in relation
to other interventions is clearly documented to enhance equitable access
to health services by the poor and vulnerable populations as well as
estimate value for money spent on PBF interventions.
2. Future design of PBF should include a partnership with the communities
to enhance access to basic health services to the poor and vulnerable
populations through community outreach programs and incentivise
demand behaviour changes through demand-side schemes to improve
health outcomes under PBF.
3.There is a need to involve the political class in the initial design of PBF
to obtain the initial political buy-in for sustainability through budgetary
approvals for the integration into the healthcare system at the county
level
4. Further research should be conducted to establish the cost-
effectiveness of the various interventions in Kenya aimed at enhancing
quality services for maternal and child health and investigate the
possibilities of merging the programs under PBF as is the case in Burundi.
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1.0 Introduction
Kenya is one of the low and middle-income countries that is implementing
the Results-Based Financing (RBF) that links payments to providers or
consumers to quantitative or qualitative indicators. RBF has been
increasingly used as a means to improve the performance of health
systems and help systems to move towards universal health coverage. In
low and middle-income countries, while some of these mechanisms have
successfully scaled up nationwide and well integrated in the national
health system, many others remain either at their early stage of
implementation or as a pilot. [1-5]. Despite the fact that RBF is
considered essential to benefit more people by ensuring equitable access
to such services, there is limited documentary evidence on how to foster
such scaling up process. Thus, further scaling up of these mechanisms
requires a better understanding of the factors that enable or hinder such
process.
The present study contributes to bridge this evidence gap by conducting a
case study, as part of a multi-country research initiative supported by the
Alliance for Health Policy and Systems Research, to examine how
Performance Based Financing (PBF) in Kenya has been developed (scaled
up) and investigate how such initiative is being implemented. PBF is a
form of RBF commonly implemented in Africa. Despite the existing efforts
to understand how the various approaches to the PBF are implemented to
improve health systems performance, in particular, there is a notable gap
in examining the interactions of such healthcare interventions with large
scale public financial management reforms such as decentralization and
devolution.
The documentation part hinged on descriptive work focused on scaling up
as a policy process. First, a timeline reporting the different key steps in
the scale up and the phenomena which triggered them was produced. We
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investigated the dynamics (process, context, content and actors) that
enabled or hindered the scaling up decision and/or implementation of the
RBF. This work was carried out in Kenya, but also in 10 other countries
(by other research teams involved in this research program). This large
set of countries allows for the drawing of lessons from cross-country
comparisons. We intended more particularly to deepen our understanding
on how the institutional rearrangements under the devolved system in
Kenya influenced the process of (PBF) scale up and the political economy
considerations that were obtained at the pilot and how they have been
integrated into the scale up politics of budget support at county and
national levels. The analysis of the institutions and the political economy
considerations was anchored on the policy contexts and the actors within
the policy process of scaling up the PBF in Kenya.
This study, therefore, aimed at documenting and analyzing the
development (scaling up) process of PBF in Arid and Semi-Arid Lands
(ASAL) regions in Kenya from July 2011 to April 2015 and draw lessons
for further scaling up and sustaining such initiative, nationally and
internationally. The study further aimed at analyzing how the re-
arrangements of the health care institutions within the newly devolved
system influenced the scaling up the process. Kenya is currently
implementing a devolved system of governance for the past two years.
The PBF is being implemented within the devolved system in which the
previously existing health care governance institutions are re-arranged
and new ones created both at the national and county levels. The
capacities of these new institutions of devolved governance in general and
of the health care delivery systems to successfully scale up the (PBF) are
yet to be properly analyzed. Some challenges had already been identified
within the healthcare institutions that were addressed through a revision
of the scaling up manual. These challenges have been noted because the
piloting of the PBF was done before the implementation of the devolved
healthcare governance institutions. However, the Kenyan case of PBF
8
scale up is unique because the entire health care system and the
supporting institutions are undergoing reforms, yet it is not properly
documented how the institutional rearrangements might enable or pose
challenges to the scaling up process.
The results of this study can provide evidence useful for scaling up and
sustain PBF nationally and perhaps internationally by conducting
implementation research that shows the possible pathways and
institutional analysis of implementing (PBF) in countries that have adopted
a devolved healthcare system. This study is important because it can
provide additional knowledge on the challenges of implementing and
sustaining PBF in the newly devolved health care system by integrating
national health financing system at the local level for improving the health
systems performance. It will, therefore, shed light on the precise
governance issues that influence scale up of PBF at the national and
county level.
2.0 Background
2.1 The Kenyan Context
Kenyan health system just like other health systems in sub-Saharan Africa
faces challenges of poor coverage, lack of infrastructure, poor retention of
health workers, equipment and unmotivated health worker force. These
challenges have contributed to poor access and utilization of basic health
services by other segments of the population notably the vulnerable
groups, thus, escalating levels of unequal access to such basic health
services. Populations occupying the Arid and Semi-Arid Lands (ASAL)
regions in Kenya are the worst hit by inequitable access to basic health
services. Such a scenario is considered a barrier to Kenya’s aim of
achieving the Millennium Development Goal of Universal Access to Health
services for all. Current efforts to address the glaring gap in access to
9
basic health services by populations living in ASAL regions include
attempts to pilot and scale up Performance Based Financing (PBF). At the
same time, Kenya is implementing a devolved system of governance that
has led to institutional reforms in various sectors including the health
sector. Under the devolved health care system, significant decision-
making power has been transferred from the national institutions to the
county institutions. New political and administrative structures such as
County Assemblies and County Directors of Health have been created to
make local decisions about the allocation of resources for health service
delivery. At the same time, payroll and human resource management for
health workers has been transferred to the devolved units albeit with
some resistance from health workers who prefer to remain under the
national government. These institutional changes within the health sector
have the potential to influence the scaling up of PBF in Kenya.
2.1.1 Health Financing Policy Context
The Kenya Health Policy (KHP) has six policy objectives and eight policy
orientations including the orientation on Health Financing. Under this
orientation, the KHP provides for “Developing and strengthening
Innovative health care financing for community mechanisms and
periodically reviewing the criteria for resource allocation and purchasing
mechanisms to improve efficiency in utilization of resources” (KHP, 2014-
2030). PBF is one such innovation as a purchasing mechanism for health
services.
2.1.2 The Performance-Based Financing Intervention
Kenya piloted a Performance-Based Financing (PBF) strategy in central
Samburu sub-county within Samburu County in 2011. Samburu County is
in the Arid and Semi-Arid Lands (ASAL) region. The piloting focused on six
10
reproductive and child health services in five quarters beginning with the
first quarter in 2011 before Kenyan health services were devolved. The
piloting was funded by the World Bank. Lessons learned from the program
are being used to scale up the PBF in 20 Counties in the ASAL region and
one county outside the ASAL region with similar indicators. The Samburu
PBF pilot is predicated on the assumption that linking incentives to
performance will contribute to improvement in access, quality and equity
of service outputs. It was funded by the World Bank, and technical
support was given by the Population Council. The pilot builds on the
Health Sector Services Fund (HSSF) as the third component of
performance incentive. The design principles of the pilot included;
separation of functions, the inclusion of the non-state sector, community
participation and verification (community voice), seek efficiency gains by
paying facilities and let facilities freely chose their inputs (autonomous
management). The steps in the implementation included; capacity
building for the then District Health Management Teams on PBF,
sensitization and training of facility in-charges and the Health Facility
Management Committee members on PBF, development of Business
Plans- Modified Quarterly Implementation Plans, signing of performance
agreements and training of joint verification teams.
The Kenyan PBF scale up is currently between the stages of adoption and
Institutionalization. An implementation manual that had been developed
before the devolution of the health care delivery system was revised to
incorporate the functions of the new institutions that have emerged in the
change process. The total available budget of the scale up is
approximately USD 20 million for the 2014/2015 financial year. It will be
implemented in the 20 Counties in the ASAL region and one additional
county outside ASAL regions. The scaling up of the PBF was initially based
on the operational manual developed by the Kenyan Government and the
Ministry of Health in 2013 as a tool to improve coverage and quality of
11
health services through a results-focused and motivated health workforce
[31]. The purchasing agent is the County Department of Health while the
provider is Government of Kenya and Faith-Based primary health facilities
(levels 2 and 3) in the ASAL Counties. There will be a Joint Verification
Team comprising County Department of Health and non-state actors such
as APHIAplus among others yet to be identified.
2.2 Study objectives
2.2.1 General Objective
1. To investigate and document the dynamics and timelines (process,
context, content and actors) that enable or hinder the scaling up
decision and/or implementation of the PBF in Kenya including how
the lessons of the Samburu PBF Pilot have been integrated into the
proposed scale-up and how the institutional re-arrangements within
the devolution have influenced the process.
Objectives
2.2.2 Specific objectives
To investigate and document the dynamics of the process, context,
content and actors that enable or hinder the scaling up decision
and/or implementation of the PBF in Kenya
To investigate the aspects of the Samburu PBF pilot that have been
integrated into the scale-up in Kenya
To investigate how the institutional re-arrangements under the
devolved system have influenced the process of PBF scale-up in
Kenya
12
To investigate the political economy considerations that were
obtained at the pilot and how they have been integrated into the
scale up (politics of budget support for scale up at county and
national level)
3.0 Methodology
3.1 Conceptual framework (Further reading and adapting to the
current study)
The study adapted Walt and Gilson framework. This framework has been
useful for analyzing the evolution of the contents of the Samburu pilot in
the scaling up process, including the reconfiguration of the institutional
system and involvement of new actors, distribution of new roles and
reconfiguration of respective functions within the devolved system in
Kenya with particular reference to how such policy processes and
involvement of new actors within the relevant institutions have influenced
the scaling up of PBF in Kenya [3,16,18, 20]. The Kenyan health system
has been analysed as a set of institutions undergoing restructuring under
devolution to co-ordinate the activities of health workers to improve
health care delivery. Healthcare as a set of institutions in Kenya interacts
with other institutions within the devolved system and which have the
power to make decisions and influence the health outcomes in the PBF
scheme. This has involved the analysis of the scaling up process of PBF
within the policy process of devolution. We have therefore used an
analytical framework drawing from new institutional economics, with
seven dimensions namely; institutions, enforcement mechanisms,
property rights, incentives, interactions between extrinsic and intrinsic
sources of motivation, behavioural changes and organizational
performance. We understand that the institutional arrangements of health
13
systems are critical to promote or hinder performance in the health sector.
An analysis of such arrangements illuminates the complexity of the
relationship between health system interventions, modification of
institutional arrangements as is now happening in Kenya under devolution
and performance of the health system [11]. We have therefore analyzed
the process of reforming institutional arrangements under devolution in
Kenya. Thus, the actors within the institutions in this framework include;
the elected Health Facility Management Committee, County Department of
Health who are the purchaser, the Ministry of Health who are the
regulator, Health Sector Services Fund, who are the fund holder, both
public and Faith-Based Organizations Primary Health Facilities as the
providers and APHIA Plus, a USAID-funded organization as non-state
actors providing verification services. Devolution in this framework will be
recognized as a policy and political process in which more decisions on
resource allocation are made by the county governments through the
county government budgeting committees and approved by the county
assemblies which is composed of locally elected political leaders with
authority on how the funds devolved to the county governments are
allocated before the implementation of any programme that is utilizing
public funds. The county assemblies receive the budget proposals for
consideration from the county departmental committees. The members of
the county assemblies have decision rights over the approval and
operationalization of the health budget in all the counties. This framework
by Walt and Gilson has also helped in the analysis of the motivations of
the various actors within the health institutions concerning the scaling up
process. The analysis therefore aimed at a descriptive timeline first the
documents, then interviews with various stakeholders to identify the
progress regarding various dimensions. We have then moved to an
analysis of the determinants of these progresses (or not) about context,
actors, process and content.
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3.2 Research Questions
What are the dynamics of the process, context, content and actors
that enable or hinder the scaling up decision and/or implementation
of the PBF in Kenya
What aspects of the Samburu PBF pilot that have been integrated
into the scale-up in Kenya
How have the institutional re-arrangements under the devolved
system influenced the process of PBF scale-up in Kenya
What political economy considerations were obtained at the pilot and
how have they been integrated into the scale up (politics of budget
support for scale up at county and national level)
3.3 Research Design
3.3.1 Study Design
The study design was both retrospective and prospective aimed at
collecting qualitative data on the process of conceptualizing, designing and
implementing the PBF pilot from 2011 to the stage of scaling up as of May
2015. Data for the study was collected mainly from qualitative interviews.
3.3.2 Instruments
The research team developed Key Informant Interview checklists (KII
checklists) for the research. The checklists will seek to;
Understand which aspects of the design factors in the scale-up have
been included in the scale up the manual and why they were
selected.
15
Understand the progress made in integrating the Samburu PBF
lesson and its contents in the scaling up manual;
Understand the extent to which the lessons of the Samburu PBF
have been integrated in the scaling up manual;
To understand the processes that have been followed from the
generation of the RBF idea to the current attempts to scale up PBF
in Kenya and help to develop a timeline for the PBF scale up
Understand the current PBF Stakeholders and the healthcare
financing partners (Contributors to healthcare financing basket).
Assess the Institutional re-arrangement under the devolution
process and how it influences scale up of PBF in Kenya
Determine the political economy considerations of the scale up of
PBF in Kenya
Understand the lessons learned and key recommendations on what
changes could be made to future PBF programs to make them more
effective in delivering sustainable services that reach targeted
populations.
The instruments were developed based on the various categories of actors
who were interviewed. Consequently, the interview checklists were
constructed for the National Health officials, County Health officials and
interview guides for the Technical Working Group (TWG) or donors who
have provided support for the piloting and scaling up of the performance-
Based Financing (PBF) in the Kenyan Health System. The instruments
were pre-tested in a neighbouring county where the PBF has been
earmarked for scaling up in Kenya.
16
3.3.3 Sample
The study design is both retrospective and prospective aimed at collecting
qualitative data on the process of conceptualizing, designing and
implementing the PBF pilot from 2011 to the process of scaling up as at
September 2015. The methods of data collection included; Desk review
and key informant interviews with selected representatives of various
institutions that were involved in the scaling up of PBF in Kenya. The
potential study participants were identified through a thorough process of
stakeholders mapping, thereafter, they were selected purposively based
on their institutions’ participation in PBF scaling up in Kenya. Telephone
contact was made with the identified officers, and they were approached
directly for an interview. Where from such an interview it emerged that
there was an officer that was particularly pertinent to the research, that
officer was contacted, and an appointment for an interview was booked to
seek clarification or corroborate the information obtained from the earlier
interviews.
3.3.4 Data Collection
i)Document review:
The first set of data for this study was collected through document review
of various documents related to the piloting of performance-based
financing (PBF) in Samburu. This included the reports on the evaluation of
the piloting of PBF including a review of the lessons learnt. The other
documents that were reviewed in this study included; the scaling up the
manual for the PBF whose formation was spearheaded by the World Bank
and the Ministry of Health together with other stakeholders who included
state and non-state actors in the scaling up of PBF in Kenya. The
information obtained from the desk review was used to help guide the
design of the instrument for collecting data through in-depth interviews
with various selected key informants. The document review also helped
17
the study to identify the various actors in the piloting and scaling up of
PBF in Kenya. These actors were later on listed for in-depth interviewing.
ii) In-depth interviews
We conducted in-depth interviews with members of the technical working
groups such as the Population Council, the donors particularly the World
Bank and Danida. Interviews were also held with staff within the African
Medical Research Foundation (AMREF) and Aphia Plus,officials at the
Ministry of Health national level who are involved in the scaling up of PBF
in Kenya, the members of the County Health Management Team involved
in the scaling up of the PBF in the selected Counties in Kenya and the
County Executive Officers (CECs) who are the political appointees of the
county government in charge of the provision of health services in the
counties. In Samburu County, in addition to interviews conducted with
members of the Samburu Central District Health Management team, the
research team visited one of the model health centres within the district to
obtain interviews regarding the process of piloting and scaling up
performance-based financing in the county at the facility level. There were
no interviews conducted with the Members of the County Assemblies
(MCAs) because they had not been introduced to the concept of the
performance- based financing in their respective counties where the
scaling up process is underway. The research team used standardized
guides for KIIs. The guide was designed for each particular target group
individually as listed below. The duration of each in-depth KII was
estimated up to 1 hour. All interviews were conducted in convenient
venues for the participants. It was realised during the interviews at the
national and county levels that the concept of the Performance-Based
Financing (PBF) has not been introduced to the political elite within Kenya
and interviews with such stakeholders although considered important for
the sustainability of the scheme regarding lobbying for budgetary support
were not expected to be productive.
18
For the KII, two types of recording were used; written notes and tape
recording. Written notes were used to provide backup copies in case of
mechanical failure or human error and to capture nonverbal cues. All
proceedings were done in languages understandable to the participants
and recordings were conducted within the boundaries of confidentiality
agreed at the time of discussions. All the twenty-two interviews conducted
with the stakeholders were transcribed using a computerised system.
Data was collected by the research team itself because of the nature of
the targeted interviewees who were mainly high-ranking staff within the
policy making institutions, the partners, the county governments and the
donors. This was done through making appointments with the identified
staff on a face-to-face basis in the English language. Where possible,
follow up interviews were done by way of telephone to seek clarifications
on knowledge gaps that were identified at the time of the interviews
3.3.5 Data Analysis
The discussions were audio-recorded in English and then transcribed into
Word format. The transcribed texts were then transferred to NVIVO 10
analysis software and analysed. Following coding of the initial 10
transcripts, a list of themes was available for categorization within a
hierarchical framework of main and sub-themes. This thematic framework
was then systematically applied to all of the interview transcripts until we
arrived at a point of saturation. Patterns and associations of the themes w
were identified using the framework of Health Policy Triangle and
compared and contrasted within and between the different groups of
informants to enhance triangulation of data. Thematic analysis was
undertaken by using a deductive analytical template derived from the
concept of Health Policy Triangle and its four components to construct
plausible explanations from the study. Validity and rigour were enhanced
during the interpretative analysis through a series of feedback sessions
19
with members of the research team and the technical back up team based
at the Institute of Tropical Medicine (ITM) in Belgium.
3.3.6 Study Limitations
This is a policy research and it is expected that this study will face some of
the challenges that are inherent in studies that involve policy issues.
Politically sensitive findings by the study can undermine the chance for
such findings being disseminated or used for policy. The study participants
included; bureaucrats working in national and county governments in the
budgetary sections, members of the County Departments of Health
(CDoH), and Health Facility Management Committee (HFMC). Time and
distance constraints could be considered as a challenge because there is a
risk of having missed interview appointments due to busy working
schedule for the potential interviewees.
20
4.0 Study Findings
4.1 The dynamics of the process, context, content and actors that
enable or hinder the scaling up decision and/or implementation of
the PBF
Introduction
This section presents the results relating to the dynamics of the process,
context, content and actors that have enabled or hindered the scaling up
decisions and/or implementation of the PBF in Kenya. The section
presents results from both the document review and the in-depth
interviews that were conducted during the study. The section is structured
into several sub-sections namely; the origins of PBF idea in Kenya, the
Samburu PBF pilot, Lessons learnt from the Samburu pilot and the
devolution process. In addition, the section presents the results of the
interviews held by various stakeholders. It describes the process, context
and the actors who are currently involved in the scaling up of PBF in
Kenya.
a) The origin of PBF idea in Kenya
The process through which the agenda of Performance-Based Financing
(PBF) got into the Kenyan health care financing policy can be traced back
to the year 2005 when Danida initiated the piloting of the Direct Facility
Funding (DFF) in the two counties of Kilifi and Kwale at the Kenyan Coast
Opwora et al. [32]. These direct cash transfers to the health facilities were
intended to enhance facility performance, community participation and
decentralised planning. This approach provided a unique opportunity to
enhance community ownership of health service delivery and increased
provider accountability to users. The evaluation of this pilot DFF was
jointly carried out in 2008 by the Kenyan government and Danida carried
21
and later used to design the Health Services Support Fund (HSSF) which
was launched in 2009 and integrated within the Kenyan Healthcare
financing system. The Health Service Support Fund (HSSF) covers all
primary health indicators in government facilities and is currently phasing
out. Furthermore, Bellows et al. [30] explain that the lessons learned from
DFF and HSSF identified potential implementation challenges such as the
reluctance of health workers to work in hardship areas. The Kenyan PBF
has been designed to fit the HSSF program building on the Kenyan
experiences in Output-Based Aid (OBA) which has successfully been
implemented through a maternal voucher system. The origins of the
Kenyan PBF can also be traced to the emerging global evidence of PBF and
its strong positive influence on provider motivation. Bellows et al. [30]
further explain that this evidence suggests that direct linkage of financing
to health outputs –both regarding quantity and quality and improves the
overall health systems performance. In addition, Kenya has in the recent
past successfully implemented direct cash transfer programs in the
education sector with an aim of improving access to quality education.
Thus, lessons learnt locally and internationally on the impact of direct cash
transfers formed the basis upon which the design of the piloting phase of
Performance-Based Financing was later anchored.
b) The Samburu pilot
The Samburu pilot for Performance-Based-Financing (PBF) was
implemented for maternal and child health (MCH) services in 26 health
facilities dispensaries and health centres in Samburu County between
September 2011 and December 2013. The aim of this pilot phase was to
test the impact of the pilot approach in two ways namely; a) improving
coverage, quality and equity of essential maternal and child health
services by incentivizing facilities for the improved performance, b)
strengthening effective supportive supervision by rewarding improved
performance of District Health Management Teams (DHMT). The pilot
22
phase of this PBF targeted six MCH indicators namely; family planning,
antenatal consultations, safe deliveries, full vaccination of children under
one, growth monitoring for children under five years and HIV testing and
counselling services. The Samburu pilot was developed based on the
structures of the Health Services Support Fund (HSSF) in which the each
of the health facilities opened bank accounts that are operated by the
Health Facility Management Committees (HFMCs). The HSSF secretariat
was responsible for the timely disbursement to the health facilities on a
quarterly basis. Calculation of the PBF payment was done based on both
the qualitative and quantitative indicators of the six service areas after the
verification process was complete. The Ministry of Health was the
regulator while the then Provincial Health Management Team (PHMT) was
the purchaser and also jointly provided supervisory and verification with
Aphiaplus, a private partner. However, the role of Aphiaplus as an
independent verifier was not properly integrated within the design of the
pilot. They only conducted the joint verification upon invitation by the
PHMT. HSSF Secretariat at the Ministry of Health was the secretariat for
the pilot. The devolved system of governance in Kenya has abolished the
provincial system and replaced with the County Government system. A
qualitative end-line evaluation of the pilot phase of was conducted in
October 2013.
c) The lessons learnt from the Samburu pilot
Some of the lessons learnt during the evaluation include; The PBF pilot
had an immense positive impact on health worker motivation, the boost in
morale occurred as a direct result of the prospect of financial
compensation, the workload of the health workers increased which they
experienced as a positive development because of anticipated higher
levels of compensation. This made the health workers forego their leave
days and also work for longer hours including working beyond the official
stipulated hours to achieve the desired indicators. There was stronger
23
cohesion and improved collaboration with the district health management
team, the demand for health services increased as characterised by long
queues, added night-shifts and more intense record-keeping work which
posed challenges to the health facilities. Community health workers
(CHWs) played a critical role in attracting more clients and tracing
defaulters. They also provided help for child welfare clinics and the PBF
incentives were usually shared with CHWs. Another lesson learnt during
the PBF pilot was that the inclusion of faith-based facilities was seen as a
success in the achievement of PBF pilot objectives. In addition, members
of the community who used the health services in the PBF pilot facilities
expressed satisfaction with the services they produced and observed that
the nurses were more pleasant, and quality services had come near their
homes. There was improved infrastructure within the health facilities.
They, however, underscored the need for better availability of drugs and
faster health services. Health workers within the facilities recommended a
more formal inclusion of Community Health Workers (CHWs) in the health
care system.
However, the pilot phase of PBF faced challenges such as lack of proper
mechanisms for verification including lack of transportation which resulted
in a heavy reliance on the ad hoc support by partners. There were also
delays in disbursements due to lack of timely verification. This contributed
to the loss of confidence in the scheme.
Further lessons learnt include the fact that community verification, despite
being in the protocol, was rarely possible as part of the verification
exercise and required further improvement. These lessons were
incorporated in the design of the scaling up of Performance-Based
Financing in Kenya. However, Bellows et, al. [30] further explain that
several inputs such as availability and strong teamwork by doctors,
nurses, paramedics and support staff, essential equipment,
24
pharmaceuticals and other consumables are required to delivery specific
health services.
d) The Devolution process in Kenya
The Kenyan government promulgated a new constitution in August 2010.
This new constitution brought into existence a new two-tier government
structure with one national government and 47 county governments which
are semi-autonomous but regulated by the national government
(Government of Kenya, 2010) [33]. Functions of several government
departments have been devolved to the county levels and the national
government only performs regulatory functions for the devolved functions.
At the moment, such devolved functions have to a great extent replicated
the decision-making structures that are existing at the national level.
There are political institutions at the national level for the elective
positions and corresponding legislative structures such as the national
assembly occupied by the Members of Parliament (MPs). There are also
several parliamentary committees responsible for oversight roles for the
functions of the various ministries as the executive arms of the
government at the national level. One such committee is the
parliamentary committee on health that plays an oversight role for the
functions of the Ministry of Health at the national level. Correspondingly,
there are county assemblies that are occupied by the Members for County
Assembly (MCAs). The County Assemblies like the national assembly have
Committees that play oversight roles in the functions of their respective
departments as the executive arms of the government. They also
scrutinize and approve the plans and budgets for their respective
departments before they are presented to the County Assemblies for final
approval before they are implemented by the County governments.
The devolved system of governance was implemented in July 2013 with
the beginning of the first financial year of the new government that was
elected into office in March 2013. This is despite the fact that the new
25
constitution was promulgated in August 2010. The Ministry of Health is
one of the government departments whose functions were fully devolved
to the county governments with the Ministry of Health headquarters in
Nairobi mainly performing policy and regulatory services. All the health
workers are employees of the County Departments of Health (CDoH) and
report to the County Executive Officers (CECs) who are equivalent of
Cabinet Secretaries (CS) at the national level and the Chief Officer of
Health, who is the equivalent of the Principal Secretary (PS) at the
national level. There is also the County Assembly Committee in-charge of
health services and a chairperson who is an MCA. The Performance-Based
Financing in Kenya is currently being implemented within this
arrangement of the devolved health system.
4.1.1 The process of scaling up of Performance Based Financing in
Kenya:
i) Ideas and Knowledge
. The process through which international policy ideas regarding
Performance-Based Financing were transferred to the Kenyan healthcare
financing system began in 2010 with an international training on Results-
Based Financing (RBF) as was explained by one of the interviewees:
…….yeah so I was saying there was training that was organized in
Mombasa whereby we were to choose two people to go and join that
training usually it is like an international training. So me and the
county nursing officer went for the training in Mombasa for the ten
days and after we had come back we were just told after the
training that now the ministry would take over so what the ministry
did after that, they invited us for a meeting in Naivasha whereby we
went to discuss I think the first meeting was about coming up with
the training manual……. (Interview, 2)
26
The Mombasa meeting was attended by participants from different
countries where Results- Based Financing (RBF) has been implemented.
The meeting that was organized by the World Bank and the Netherlands
Government aimed at introducing the concept of PBF to the participating
countries. One of the interviewees thus mentioned:
….. Last year in May…it was done by World Bank and someone from
that country where Hague is which one?
I2: Netherlands.
R: Yes from Netherlands…it’s an international course.
The Mombasa meeting was attended by participants from different
countries including; Rwanda, Senegal, Iraq, Cameroon, Sierra Leone,
Nigeria, Ghana, Uganda, Burundi and Mozambique among other countries
that are implementing Results Based Financing. This meeting in Mombasa
marked the process through which the ideas and knowledge was
transferred from different institutions to set the policy agenda that drives
the implementation of PBF in Kenya. In the Kenyan case of PBF, several
research to evaluate the performance of the piloted aspects of Output-
Based-Aid (OBA), voucher schemes as well as an evolving global evidence
of PBF that was shared in the international meeting in Mombasa has
formed the basis of health reforms initiatives. It is noteworthy that the
Ministry of Health took over the initiative after the Mombasa meeting to
begin the internal process of implementing the ideas of PBF when the
Ministry used its structures with financial support from the World Bank
and technical support from Population Council to pilot the Samburu PBF.
This is an indication of the process of translating ideas and knowledge
concerning PBF in Kenya. This process began in 2011 when health workers
in Samburu Central were trained on PBF concept based on an
internationally developed manual that was later domesticated to be in line
with the Kenyan context by incorporating the views of several Kenyan
27
stakeholders.
ii) Country ownership of PBF and integration into health system
The National level processes for scaling up PBF in Kenya have been
categorized into the following thematic areas; i) Development of the scale
up manual, ii) Training of the County representatives on the PBF concept
and its implementation including orientation of the lessons learnt from the
Samburu pilot iii) Sensitization meetings for the County representatives on
the implementation of the scaling up of the PBF.
a) Development of the scale up manual
The development of the manual was started immediately after the
evaluation of the Samburu pilot in January 2013. This process was
informed by the lessons learnt from the Samburu pilot and the then
existing structures for the healthcare system that were based on the
national government before the structures for the devolved system of
governance and healthcare were put in place in July 2013. However, the
manual was subjected to another round of revision to upgrade it to be
responsive to the structures of devolution and more particularly to the
structures of the devolved healthcare system. The second reason for the
revision of the manual was to harmonize the range of indicators from the
first PBF training and the
one from World Health Organization (WHO) as was explained by one of
the Key stakeholders during an interview:
……. then we identified, we looked at the tools that we came up with
from Nairobi and the tools that we received from the performance-
based financing and when we analyzed the tools, the agenda is one
however, the range of the indicators that the draft manual is talking
28
about from the ministry has 10 indicators and the other one from
the WHO facilitators has 25, and we looked at them and said they
were both good…...(Interview,2)
It is clearly shown from the above verbatim quote that the current manual
for scaling up PBF in Kenya has been harmonized to incorporate the WHO
indicators. This could perhaps explain how the PBF indicators in Kenya
were increased from the original six during the piloting phase to 10 in the
newly developed manual for scaling up. However, stakeholders in Kenya
have a feeling that the process of integrating PBF into the Kenyan
healthcare financing policy is slow as compared to other African countries
perhaps because Kenya is in transition from the centralized government to
devolution and each of these two levels of governance have not put in
place intergovernmental coordinating mechanisms to enhance PBF scaling
up. Some of the informants thus explained;
………..The only thing is that I think in Kenya we are a bit late as
compared to other African countries in implementing PBF and one of
it is because they had not been aligned with our policy, but now it
seems the ministry has taken it up, and all that’s needed is the
ministry to do a write up that this is the way to go…….(Interview, 4).
……..yeah yeah in fact the manual was still very new in Kenya we
didn’t have a manual for PBF so they were trying to try and get our
inputs based on the training which areas we could improve on and
even the second one it was the same the second one was more also
developing the training materials for the roll out so in both meetings
we had a consultant who was hired by the world bank he is called I
think doctor XXXXX he is a guy from Zambia we have had him in
both meetings…… (interview 4)
The stakeholders have underscored the need to have the ideas behind the
PBF disseminated to the lower facilities in the counties to facilitate the
29
buy-in. Such a move would help to integrate the Kenyan PBF into the
Health care system.
b) Training of the County Representatives
The process of training the county representatives has not been
accomplished in Kenya with respect to scaling up of the Performance-
Based Financing (PBF). This has been considered as a delay in the process
of scaling up of Performance-Based Financing. The process of training the
county representatives has been initiated by selection of different cadres
of health workers to be trained as Trainers of Trainers (ToTs). This was
explained by the key informants during the interviews as illustrated in one
of the interview sessions:
……Interviewer: Who in the county will be trained….. what is the
context, do we have a key person in the county…who is going to be
under PBF….
……Response: We actually identified cadres that should be involved
as ToTs because we left it open but one of them is the nursing
officer in charge of the county as a ToT, the medical records person
at the county level, Public Health Nurse then the health
administrative officer at county level because we had one in
Naivasha and they are involved in financing that is very important.
So they were four people who would be trained as ToTs and then
train the key members of health facilities and including health
management committees because they have to be
trained.(Interview, 3)
Training of Trainers (ToTs) is the last step in the efforts to build the
capacity of relevant county departments to scale up PBF and eventually
integrate it into the county health system.
30
c) Orientation of lessons learnt from Samburu pilot
Orientation of the lessons learnt from Samburu pilot formed an important
segment of the process of scaling up PBF in Kenya. This process involved
carrying out a rapid assessment of basic inputs at the health facilities
which are necessary to deliver quality services and to prepare a service
delivery improvement plans based on the lessons learnt from Samburu
pilot. The orientation process also involved reminding the facilities to hold
quarterly committee meetings. The main message in orientation of lessons
learnt from the Samburu pilot was to create local knowledge on the
benefits of changed mode of financing from the normal salary to funding
outputs as explained below:
…….Yes you know previously we had discussed this….now we are
funding the outputs. We have been giving people money to
work….now we are asking people to work and pay them for work
done. So they will be entering into a performance agreement with
the facilities and verification teams…..(Interview, 2)
…….Interviewer: how do the lessons learnt from that Samburu pilot
inform what you are doing now?
……..Respondent: the lessons learnt in Samburu during that meeting
there was no in depth sharing of the lessons learnt in Samburu
because really they said it was doable, it helps in improving service
utilization and improvement on the health indicators and it is
difficult in terms when it comes to verification of the data, somehow
it is difficult as such the tools are long and probably needs a lot of
commitment and a team that is very focused and as a county, I
think we are up to the task…. (Interview, 4)
The difficulties associated with verification of the results that lead to
payment of performance- based financing has been raised by different
stakeholders interviewed as one aspect that is yet to be properly handled
31
even as the performance-based financing is being scaled up. The main
problem has been that of data reliability. The basis for calculating the
benefits has not been clear and it has been difficult to know whether such
improved indicators were realized only from the activities of the piloting of
PBF or other interventions targeting maternal health in Kenya. The
stakeholders during the interviews argued that the same indicators for
which the Samburu PBF were based, were also the focus of other maternal
and child health indicators under the free maternity services in Kenya and
the safe motherhood vouchers (OBA) program that promoted maternity
health in Samburu and other counties. One of the plausible suggestions to
create effective mechanisms for verification is to invest in electronic
means of verification as was explained by one of the informants:
…… The trick to get it working is in the system and you will probably
have to have some sort of electronic means of verification. But the
first time we had claims from Samburu, it was significantly different
from what the district had reported with DHIS and it took six
months to agree on figures from the number of facilities that had
participated. Data reliability is key to have a well functioning
system. You cannot avoid some sort of electronic verification in the
long run….. (Interview, 7)
Thus, the problem of data reliability has been reported in other output-
based-aid (OBA) initiatives in Kenya. For instance, it has been argued that
the newly introduced free maternity services in public health facilities has
contributed to invalid or delayed payments of benefits as was explained by
a stakeholder during the interview;
……..One of the issues that cropped up about the 22 participating
facilities in PBF on top of that they also got HSSF on top of that
some of them were involved in the voucher scheme and coming off
the president’s initiative on free maternity so some of them got
32
refunded 3 times for the same thing so there has to be one
system…….(Interview,7)
The process of sensitizing the counties regarding scaling up of PBF is
noted to be at different stages for different countries. For instance, the
seven counties in the Northern part of Kenya have formed a coalition that
the World Bank trained in March this year (2015) and facilitated to have
the necessary structures to begin the scaling up of PBF in their counties.
According to a key informant, these were the counties that had expressed
their readiness to begin the scaling up and were selected for training in
Nairobi to facilitate the process of implementation in their counties. One of
the informants thus explained:
………..for example the last two days we sat with 7 counties to see
how we can fine tune the idea, see if the counties can start playing
the role and what kind of performance contracting they can do in
terms of segregation of functions who will do what and those are the
things we are talking to county governments about. It’s to get them
on the table and bring them together so the North Eastern counties
have formed a coalition so they are working together with the
secretariat which made it easier for us to engage…….(Interview,6)
As at the end of May 2015, sensitization of the main actors in the counties
formed part of the process of implementing the scaling up of PBF. The
process of sensitization of different stakeholders at the county level was
aimed at laying the ground for acceptability or initial buy-in of the idea at
the county level. The sensitization process targeted the major actors at
the county level such as the governors and their deputies and the County
Executive officer for health. The sensitization process also targeted the
relevant members of the county assemblies in the counties as part of the
efforts to align the process of implementing the scale up of PBF with the
county political establishment. One of the key informants explained that
the governors who are now heading the county governments have been
33
informed at a meeting of stakeholders about the implementation of PBF in
their counties and the need for initial political buy-in. The informants
explained that this would provide a soft landing or rather appropriate
reception that would enhance the flow of PBF funds from the county
treasury for the implementation of various PBF activities.
Besides involving the governors and other senior county government
officers, this process also involved putting up the necessary structures.
Infrastructural development of health facilities has been done after after
carrying out a gap assessment in the facilities that were earmarked for
scaling up of (PBF). This was done by developing action plans aimed at
addressing the gaps under the guidance of the World Bank. In addition,
the process involved putting up committees at national, county and facility
levels and role definition for various stakeholders such as the purchaser,
the verifier and the regulators as was explained in one of the interviews.
……..So from this month (April 2015) till July World Bank is giving
some money to these counties. That money will be used to fill the
gaps that the facilities have. Last week when we were there we also
opened accounts we formed an agreement between World Bank,
Ministry of health headquarters and the counties where the governor
and the CS of health will sign an agreement so that will be engaged
for the whole project…….(Interview, 13)
…… we are starting now with the H4 partners (partners who have
been carrying out health interventions in the county and World
Bank, WHO, UNFPA and UNICEF) as I had earlier indicated then
probably why the two programs are going to complement each other
is basically the fact that you cannot probably measure someone if
you have not facilitated them in a lay man’s language that is why we
have a gap filling program just to ensure that the facility has all the
equipment it requires, all the commodities, the staff are there, some
of them are connected to water and electricity. Once we have put
34
the basic systems in place, someone cannot say I cannot deliver
because of this shortcomings that is why the two programs are
complimentary, we will do the gap filling, once we have done the
gap filling, most facilities will be equipped, most facilities will have
the basic infrastructure in place then from there you can be able to
bring in the RBF……..(Interview 13)
The World Bank advanced funds in the seven frontier counties that were
selected in one of the sensitization meetings in Nairobi in March 2015.
These funds were disbursed only after the counties had put in place the
required structures such as the committees, opening of a PBF fund
account, separate from the general county account to avoid the
bureaucracies that were observed during the Samburu piloting and which
partly contributed to delays in payment of benefits or incentives. This
process was explained in one of the stakeholder interviews;
………Yes for all the 7 counties. They have already signed that
agreement. So the county has signed the CS will sign and that will
be the basis for the agreement and there are other things like we
have to have committees, facility based committees, county-based
committees and national based committee for the implementation.
Then there are other issues that are also being put in place. There
are people called purchase holders, there are independent verifiers,
service providers at facilities there is a committee at national level
called health care finance department…….(Interview 6)
The stakeholders further explained that the PBF structures being put in
place are not parallel to the existing structures within the counties and
that they will have to obtain approval by the county assembly through the
county treasurer and follow the existing county healthcare finance system.
This argument is illustrated in the response below which was obtained
from one of the stakeholders at the county level:
35
…….You know this system is not developing a parallel structure,
what we are doing is the plan we are developing must capture that
and be approved by the county assembly through the county
treasurer. So it will follow the normal county health care finance
system. So we will develop our plan, identify the gaps…how much is
the county contributing and the gaps that the World Bank is going to
chip in so this budget will go through the normal way. And this
account that we opened it was not the Ministry that opened, it was
the County treasury that opened. So we requested an account and
they are signatories and we are also signatories. Our chief is a
signatory, the finance chief is also a signatory the way we do with
other accounts. The only difference with this account is that it will
not be subjected to the county money e.g. the way they do with
public money…….(Interview, 10)
The Kenyan government is currently operating an Integrated Financial
Management Information System (IFMIS) for the expenditure of all the
public funds both at the national and county levels. Some stakeholders
argued during the interviews that the bureaucracies associated with this
system can delay the processing of incentives for the PBF including timely
purchasing of supplies necessary for the realisation of output indicators
under the PBF. This financial management system and other lessons
learnt from the Samburu pilot might have influenced the formation of a
special fund account for scaling up of PBF at the county level.
4.1.2 Context
4.1.2.1 Macro-contextual issues
Kenya as compared to other countries around the globe is implementing
PBF under a background of increased debate on the need to enhance
accessibility to services to meet the MDG goals such as reduction of
Maternal and Child Health (MCH), HIV/AIDS among other health
36
indicators. Performance-Based Financing in Kenya has been developed
within the context where national policies such as the free primary and
day secondary education had improved educational outcomes through
programs that enabled direct cash transfers to schools [30]. Furthermore,
[30], argues that experiences obtained from such direct transfers to
schools in Kenya helped to identify potential implementation challenges
such as the reluctance of staff to work in hardship areas. Kenya
introduced free primary and day secondary school in January 2003.
Information obtained from one of the interviews with a stakeholder
involved in the scaling up of Performance-Based Financing in Kenya shows
that there are no capacity related gaps in training of health workers to
deliver quality health services, the problem in Kenya lies with health
worker motivation which has been considered as the main barrier to
achieving improved health outcomes;
…….Kenya staff has the highest competency compared to all
countries in the developing world including India. The problem is
that it does not get translated to services that are the challenge. It’s
the incentives to make them function and give them xxx so if you
look at the comparison globally, we did what is known as Service
Quality survey and used a similar instrument in the region and
Kenya is top of the list… it covered very common conditions about 5
or 6, and in all conditions, Kenyans are close to 78 percent but
practice that knowledge is lowest in Kenya so that knowledge of 70-
80 percent drops to 30% when it comes to action. The solution for
Kenya is not to do training, there’s too much of training that is not
value for money……..(Interview, 6)
According to this key informant, the solution to the poor health services
delivery in Kenya lies with the provision of incentives to health workers to
help achieve the desired outcomes through a motivated and dedicated
health worker. This argument is consistent with the current efforts by the
37
Kenyan Ministry of Health, the development partners and practitioners to
scale up the Performance-Based Financing (PBF) after the lessons of
piloting in Samburu. Stakeholders during the interviews narrated how the
broader policy framework within the health sector including the
community health strategy provide contextual factors that enable scaling
up of PBF as is shown in one of the interviews below;
………So coming to the broader policy frame work…. it helped to
evolve the broader RBF frame work in Kenya and its important to
consider that RBF is one method of financing and one should not see
one method of financing as a solution to all problems faced by
society. RBF fits into that particular context. It has got stronger
supply side focus it can become demand side also considering the
linkage it has with community based systems but still it’s a good
supply side intervention. (Interview 6)
Apart from devolution, PBF in Kenya is being scaled up in a context where
there are other interventions that target the same indicators. For instance,
the free maternity services policy in public health facilities has been
implemented in Kenya since the new government took over in 2013. The
Kenyan first lady has also initiated the ‘Beyond Zero’ campaign –a
campaign with donations from different stakeholders including private
sector with an aim of ensuring quality and safe delivery for all Kenyan
mothers. This campaign has received national political support beyond the
ruling coalition. In addition, the German Development Bank (KfW) and
other development partners have implemented the safe motherhood
maternity voucher as an output-based-aid (OBA) targeting improvement
of MCH indicators in several counties in Kenya. These different policy
interventions have the potential to influence the scaling up of PBF in
Kenya. The existence of Health Services Support Fund (HSSF) has also
provided contextual basis upon which the PBF can ride on, particularly the
38
fact that health facilities countrywide had opened bank accounts through
which the PBF funds would be channeled for benefits sharing.
Devolution of health services is an important contextual issue in the
scaling up of Performance-Based Financing (PBF) in Kenya. There is an
on-going debate in Kenya regarding the status of health services before
and now after devolution. An editorial report entitled: ‘Health sector is on
the brink of collapse’ carried in a leading daily newspaper in Kenya (Daily
Nation of 18/08/2015) shows that the health services are facing
challenges after the devolution. Different stakeholders in the political
ranks in the country are reportedly arguing about the ability and the
inability of the county governments to run health services with a number
of health workers strikes reported due to delayed salaries, reduced
allowances, ethnic discrimination in promotions and lack of facilities as
some of the reasons that have forced doctors and other health workers to
resign from the government and go into private practice. Currently, there
is a raging debate on whether Kenya needs to reconsider its health policy
with regard to devolution so that such services are taken back to the
national government in order to restore quality health services. In fact,
there is a health bill pending in parliament for debate with an intention of
reverting the health services to the national level.
4.1.3 Actors in scaling up of Performance-Based-Financing (PBF)
in Kenya
Introduction
This section describes the various activities, roles and positions of various
actors in the process of scaling up PBF in Kenya. It explains the roles of
development partners and the Kenyan civil servants, politicians and the
private sector in influencing the process of PBF scaling up in Kenya. This
39
section, therefore,, presents these actors into two categories namely; the
development partners and the national level actors.
i) Development Partners
There are several actors who have been identified in this study to be or
have been involved in the process of scaling up PBF within the existing
health policy framework in Kenya. These actors have played different roles
not in their individual capacities but as members of the various
organizations that they have represented. They include; the World Health
Organization (WHO) whose guidelines have been used to develop
indicators for PBF in Kenya but has remained inactive in the process of
scaling up PBF in Kenya. The Netherlands government as an actor in the
scaling up Performance-Based Financing in Kenya featured only once in
the initial International meeting in Mombasa where the idea of PBF was
introduced. The Netherlands government participated alongside the World
Bank as co-sponsors and facilitators for the meeting. The Danish
International Development Assistance (Danida) has played an important
role in the provision of the contextual basis upon which PBF piloting and
scaling up has been implemented in Kenya. For instance, Danida
supported the piloting of Direct Facility Funding (DFF) in 2005, leading to
the development of structures for Health Services Support Fund (HSSF) in
2009. The structures for HSSF developed by Danida were used for piloting
of PBF and the development of the initial scaling up the manual for PBF in
Kenya. However, it has been difficult to estimate Danida’s interest in the
scaling up of Performance-Based Financing (PBF) in Kenya. According to
one of the stakeholders, Danida has shown significant interest in
supporting social protection programs in the health sector in sub-Saharan
Africa. However, Danida as an important player in the Kenyan Health
Sector Reform program has played no role in the scaling up of PBF as
shown in the interview excerpt below;
40
……..Because we have not during this present phase of the health
sector support to Kenya been involved in Performance-Based
Financing even under the HSSF and piloting in Samburu, Danida
funding was not spent there, it was exclusively GOK and World Bank
funding. So whatever I have can only be from what I have seen
from the sidelines by sitting in the HSSF secretariat…….(Interview,7)
Further probing regarding the position of Danida in PBF showed that they
do not believe in the process, particularly the verification and the payment
of benefits due to the fact that it is not electronically based and is prone to
abuse and manipulation by the actors who can demand for payment on
indicators that are not specifically the outcome of the PBF.
The World Bank has played the lead role in scaling up of Performance-
Based Financing in Kenya. The bank has done this through spearheading
the initial assessment of the reforms within the Kenyan health system in
2010, supporting and facilitating the international stakeholder training in
2011 and financing and technically supporting the implementation of the
Samburu pilot. World Bank is currently spearheading the scaling up of PBF
in Kenya and has set aside a total of USD 20 million for this purpose. The
Bank has taken the lead in providing both technical and financial support
in the scaling up of Performance-Based Financing. The Kenyan
government through the ministry of health currently depends solely on the
funding and technical support from the Bank to scale up the performance-
based financing. So far there is no evidence that the government has
allocated funds for the scaling up of PBF in addition to what the bank has
given. Thus, the Bank becomes the most influential actor in the scaling up
of PBF in Kenya. There is evidence that the World Bank is pushing the
agenda through the Ministry of Health and down to the county
governments as shown in the verbatim quote from an interview below;
……Let me clarify… the pooled account would be created under the
county health department with the chief officer of the county as the
41
accounting officer, so what we are talking about is what…. we
created a similar concept from India…we created societies that have
a separate account in support of TB, HIV, malaria. And it is the chief
executive who has the number secretly and then someone like a
district commissioner was chairing and finance. But the access to
money is available, and the counties do not lose money they end up
spending. Money does not go back…...(Interview,6)
……..All the twenty, the scope of work will be in all the twenty, but
we have proposed it to start with the seven then inform the rest…it
depends on the willingness to come and join because we want to
have more accountability; we do not want the money to go directly
to the county revenue funds then you don’t know where it will go.
So it’s to create a different account and have accountability
mechanisms in place and having a performance agreement and then
have a work plan that is not parallel with the county integrated plan.
So it is in line with the overall annual work plan…….Interview,6
R: Let me clarify… the pooled account would be created under the
county health department with the chief officer of the county as the
accounting officer, so what we are talking about is what…. we
created a similar concept from India…we created societies which
have a separate account in support of TB, HIV, malaria. And it is the
chief executive who has the number secretly and then someone like
a district commissioner was chairing and finance. But the access to
money is available, and the counties do not lose money they end up
spending. Money does not go back……(Interview, 6)
According to this key informant, to institutionalize the PBF in the financial
system and to borrow from experiences of supporting TB, HIV and malaria
from other countries such as India, the World Bank influenced the creation
of a fund for health where the county department can access funds to run
their services and avoid bureaucracy. In fact, performance-based budgets
42
have been included in the national budget and the Kenyan government is
actively moving to a much broader policy level to performance-based
dispensation through the County Integrated Development Plans (CIDPs).
The stakeholders argued that the principle was aimed at avoiding wastage
and making services be cost effective. Thus, the World Bank has featured
as the main actor in the institutionalization of the PBF in the Kenyan
healthcare financing system.
ii) National Level Actors
National level actors for scaling PBF in Kenya include; the Ministry of
Health and its Department of Planning, Policy and Healthcare Financing,
the Treasury, the development partners such as Aphia Plus, the Population
Council, the County Governments including the members of the county
assembly and the health facilities where the scaling up of PBF is currently
taking place. In addition, the community health units have been identified
as important actors in the scaling up of PBF in Kenya. The community
health units have been identified after the piloting of PBF in Samburu and
are now being included in the scaling up process. According to the Kenyan
health policy, community health units are considered as level one of the
healthcare system, but they have remained inactive due to lack of funding
at that level.
The Department of Planning, Policy and Healthcare Financing is
responsible for the coordination of the scaling up of PBF in the selected
counties in Kenya. It plays this role by working closely with the World
Bank and the relevant actors in the counties for scaling up of the PBF. One
of the critical roles that the department is currently involved in is the
coordination of meetings where the milestones for the scaling up of PBF
are conducted. As a consequence, several meetings have been organized
to implement the scaling up of PBF. The last in the series of the meetings
organized by the World Bank and the Department has been to train the
Trainers of Trainers (ToTs) who are supposed to cascade the training on
43
PBF among the in-charges of health facilities. The involvement of the
Department of Planning, Policy and Healthcare Financing in PBF can be
illustrated by the following two verbatim quotations;
………and we were told to nominate 3 TOTs to be trained so that they
will come back to cascade the information to the facility level and we
have already nominated them. And they are waiting to be called any
time. It was scheduled for this week from Monday, but
unfortunately, they cancelled……..
………she told us she was in Zimbabwe again they were looking at
the same RBF they were looking at what are the good things which
are working in Zimbabwe and I noticed also it is like our deputy
governor also went to Zimbabwe with that team……. (Interview,22)
Apart from the Ministry of Health and the World Bank, Aphia Plus –a USaid
funded project is one of the actors in the PBF scaling up as the verifier.
Their role as the independent verifier is properly positioned within the
manual and other stakeholders hope that they will be effective in
performing their duties as the independent verifier. Verification is
considered as one of the challenges during the piloting of PBF in Samburu.
This is because the position of the verifier was not properly articulated in
the contracting agreement and they only participated in the verification
upon invitation by the then Provincial Health Management Team (PHMT).
….I just want to share with you something on partners. We have
partners on the ground and they are very supportive. Amref and
World Vision have been very supportive to us. They have supported
us in training the CHWs and therefore establishing a vibrant
community health unit where we find that almost every CHW is very
active. But this goes back to the health workers in the facility they
feel very motivated…..(Interview, 22)
44
…….Question : okay now the other question I should ask is the level
of participation of other partners in the process of RBF besides the
WHO, the World Bank, how have the other partners who are
involved in health in this county been involved in the whole
process……..
……..Response : like I told you earlier, the partners that we are
working very closely with in RBF is the World Vision, Amref, and also
International Medical Corps in Samburu North and East those are
the partners we have been working very closely with and we have
been engaging them mostly in doing the verification, we do
verification together and you will find that most of the verifications
we do it together with our support supervision so you will find that
most of the supervisions of those verifications have been supported
by those partners, so the support we are actually getting from them
is in terms of supervision, it is them who have actually been
supporting in doing the support supervision…….(Interview,16)
The county governments in Kenya and particularly the County Department
of Health (CDoH), the Governor, the County Executive Officer in charge of
Health, The County Assembly, and the County Assembly committee in
charge of health form the bulk of the actors at the county level.
Furthermore, the Health Facility Management Committees (HFMCs)
including the in-charges of health facilities and the Community Health
Units including the Community Health Workers also form the bulk of
actors below the county levels where the actual implementation of PBF is
expected to take place. However, these actors can only play a role in the
scaling up of PBF if they are provided with the right information and the
support they receive from other stakeholders high up in the ladder such as
the World Bank and the Ministry of Health as it is indicated in the excerpt
from the interview below;
45
……..Last week when we were there we also opened accounts, we
formed an agreement between World Bank, Ministry of health
headquarters and the counties where the governor and the Cabinet
Secretary (CS) of health will sign an agreement so that will be
engaged for the whole project……. (Interview,11)
Other actors at the county level include; the political actors such as the
governors, the County Executive Officer (CEC) in-charge of health
services, the County Assembly, the county Assembly Health Committee
and the Member of County Assembly who chairs the health committee.
These actors are supposed to play a role in pushing the agenda for
institutionalising the PBF into the county planning and financial system as
a political agenda. Besides the political actors in the PBF scaling up, there
are civil servants who are expected to implement the scaling up a
program within the counties. These include; the chief officer of health
services, the head of nursing services, the health information officer and
the in-charges of health facilities that have been earmarked for the scaling
up. Thus, there are different actors (political and civil servants) with
different orientation and interests in health services at the county level. It
would be interesting to analyse how these two different interests (political
and professional) influence the scaling up of PBF in Kenya. So far, there
have been trainings earmarked for the civil servants who are supposed to
be trained as Trainers of Trainers (ToTs). This training that was later
scheduled to take place in June was postponed due to changes at the
central co-ordinating unit at the Ministry of Health due to staff transfers,
others retiring as at the beginning of the new financial year in July. The
training was later carried out in the first week of September, 2015.
46
4.2 Effects of Institutional Re-arrangements Under the Devolved
Governance on PBF Scale up in Kenya
4.2.1) Introduction
Health services have undergone tremendous transformation since the
onset of the devolved government. This is because health is a devolved
function with the National Government retaining the functions of health
policy, regulation, capacity building and technical assistance to the
counties and the National referral health facilities. The County
Governments, on the other hand, are responsible for county health
facilities and pharmacies, ambulance services, promotion of primary
health care among others. The PBF indicators earmarked for the scaling
up are categorised under the services provided by the county government.
This shows that the success of PBF scaling in Kenya to a great extent is
dependent on the functioning of the devolved health system in particular
and the proper functioning of the county government in general.
Information obtained from the interviews conducted in this study shows
that devolution of health services is partly seen an enabler or a barrier to
successful scaling up of PBF in Kenya from a pilot scheme to a healthcare
financing system. This section, therefore, is divided into two. The first
section presents data which shows that devolution of health services is an
enabler in the scaling up of PBF in Kenya while the second section
presents data which explains how devolution is considered a barrier to
successful scaling up of PBF.
4.2.2) Devolution as an enabler to scaling up of PBF
Some explanations were provided by the different stakeholders in this
study as to why they considered devolution of health services in Kenya as
an enabler in the scaling up of PBF in the Kenyan healthcare system.
These reasons included; localised decision-making process, improvement
47
in infrastructure, strengthened accountability, ability to activate or
strengthen community health strategy and the ability to enhance political
buy-in for the scaling up of PBF. This last point will be discussed under the
section of this report on the political economy considerations of scaling up
PBF in Kenya.
a) Localised decision-making process
The decision-making process has been made faster and relevant to the
existing local settings under the devolved governance system. This is
because the key people involved in the decision-making process are living
and working within the same environment as the people who are
supposed to be served –mainly their electorate. According to the
informants in this study, this localised decision-making process has
arguably improved chances of enhancing the delivery of health services
and created an appropriate environment through which the health workers
and other stakeholders can more specifically enhance the prospects for
scaling up PBF. The following excerpts from the interviewees thus
explained how the devolved governance has enhanced implementation of
activities in the interior parts of the counties where the previous national
government could not reach.
..… because at county level we can understand the challenges facing
health than before it was very difficult for a person to propose that
he can supervise and implement activities in the interior parts of this
country…… (Interview, 10)
………With devolution we have been able to prioritize than before
then the commitment to allocate resources than before are there.
Even though at times the money allocated is not enough but
devolution is the way forward. (Interview, 8)
48
………….in fact, supervision has become much more thorough
because people are just here, decision making can be made very
fast because sometimes we used to have those cases whereby in
case of disciplinary issues you have to start here send to
Nairobi……..(Interview, 12)
It was further emphasized during the interviews that the scaling up of PBF
if well implemented can be enhanced by the efficiency of the local
decision-making process regarding the allocation of resources and local
negotiations regarding priority spending areas within the county
governments. One of the informants during the interview thus explained:
…..with devolution in terms of disbursement of funds you find that if
the process is streamlined it can be faster and when it comes to
setting the indicators that would be case by case per county
because they have unique problems and in terms of verification
visits that is where the county can come in with the funds to
strengthen the process, it will unclog even this process and the back
and forth and ensuring the monitoring is done, and better managed.
As well as advocacy done properly at county level, it is important to
tell them the benefits…. (Interview, 14)
The informants argued that the successful scaling up of PBF does not only
depend on the decisions made concerning healthcare but also in the
overall improvement of the general infrastructure including the road
network, water and electricity connectivity within the counties and health
facilities.
Another important aspect of devolution that is associated with localised
decision making is the opportunities for the local communities to
participate in decision making processes in the provision of health
services. Some of the counties are putting up systems to allow the
representation and participation of the local community in the budgeting
49
for health services, thus incorporating the voices of the community
members in the resource allocation for health services under the devolved
government. In terms of scaling up of PBF, it is anticipated that such a
localised voice can contribute to the successful scaling up of PBF if the
community and its representatives are convinced that the system is being
scaled up in the interest of the communities. One informant thus
explained;
………the beauty of the devolved functions I mean the devolved
government is that the people’s voice is heard and that is why
even in that budget when you are spending, ensure there was
a community representative, I had a shadowfor health there
coming from the community and looking at what we are
proposing this is it really… they said they have also heard the
issues from the common man, so things, whatever you are
putting, we are not imposing like the national government
used to…………(Interview, 19).
b) Improvement in Infrastructure
An important element of infrastructure that has been mentioned in several
interviews with the key stakeholders at the county level is the expansion
or construction of more maternity wards, purchase of ambulances which
are fuelled, general expansion of health facilities as well as construction of
rural feeder roads within the counties. The purchase and fuelling of
ambulances by the county governments as well as the construction of
roads are considered by the stakeholders as enhancing the referral and
ambulant services to respond to emergency needs for health services and
more particularly health facility-based skilled deliveries. Health facility
skilled deliveries is one of the key indicators in the scaling up of PBF in
Kenya and for which incentives are paid to the health workers involved.
One of the key informants thus explained:
50
……..We have been able to improve the maternities, buy more
vehicles….supervision is closer. We can identify our challenges
better than National government. Given time …15 years to come
things will be better, its unfortunate for those who did not
experience the old system they might not understand the
benefits…...(Interview,12)
The above quotation further illustrates the devolved system has improved
the process of decision making that has enabled the counties to invest
devolved funds in expenses that can improve health. The quotation
provides a comparison with the decision-making process previously under
the national government. The stakeholders at the county level were in
favour of the devolved system and emphasized the fact that the devolved
system has more benefits that can lead to laying the required
infrastructure that can support the scaling up of PBF in Kenya. Information
obtained from the interviewees further show that most counties allocated
more devolved funds for infrastructure than what was previously given
under the national government. This elevated expenditure on
infrastructure has ignored the invisible but critical services such as the
provision of drugs and other diagnostic equipment. There were complaints
that more buildings in terms of maternity wards and other dispensaries
were being constructed by the county governments but were not equipped
to provide health services due to lack of staff, drugs and diagnostic
equipment. However, such enhanced allocations have improved
infrastructure in the counties which is suitable for scaling up of PBF. One
of the interviewees thus explained:
……Most counties gave more than what they were giving earlier. And
they have also improved infrastructure…things like water and other
things which were not there before. If you speak to governor xxxxx
he promised to get water to the hospital and then it took many days
51
to do that so until that is done he had to sort that in tankers, so that
is how things started first…...(Interview, 6)
They argued that the opportunity to improve accessibility to health
services by the majority of the populations in the counties is in the
infrastructure and if the county governments have a good buy-in for the
PBF, then even the PBF will contribute greatly in promoting accessibility to
the services. This is because the PBF facilities will receive additional
money from the PBF scheme which they can further invest to improve the
infrastructure within the health facilities and enhance accessibility to
quality health services. This argument is plausible due to the fact that the
design of PBF in Kenya takes into consideration the verification of both the
quantitative and qualitative indicators for the facilities and health workers
to receive incentives.
c) Strengthened Accountability
There was a recurrent explanation by the stakeholders in this study that
devolution itself has strengthened accountability and created new
opportunities for accountability because of the localised decision making
processes. Health workers and other civil servants are now supervised by
the county government which is within a closer proximity and makes
workers more accountable and responsive in performing their duties. This
behaviour by the workers at county level is reinforced by the earlier
exercise to do human resource audit in all the counties to weed out ghost
workers as well as identify and take appropriate action against workers
who absent themselves from work for longer periods to work in other
places and earn two salaries. One of the leading actors in the PBF scaling
up process in Kenya thus explained:
Respondent: Devolution created very new opportunities because of
that strengthened accountability.
I: Devolution strengthened accountability….?
52
…….In a way…. because they have done the human resource audit
doctors and other staff who were earlier working somewhere else
and earning money here….those are the ones who immediately got
curtailed. Because the governors and County Assembly members
were visiting these places more regularly so that was the good part.
A good part of the public expenditure of health…goes to salary so if
the human resource is not available because close to a third of the
staff are not available at their place of work… (Interview,6)
The strengthened accountability due to devolution is expected to provide a
working environment that will enhance service delivery. Such
accountability can address the problem of service gap due to staff
abseiteeism as was claimed by one of the informants earlier in this report.
Furthermore, there are institutional structures within the county
governments that have been put in place to ensure the successful scaling
up of the PBF. These structures include various committees such as
county steering committee chaired by the County Executive officer of
Health –who is a political appointee of the government. The county
department of health is expected to be the purchaser and is headed by a
civil servant. Members of the civil society, human rights organizations and
Non Governmental Organizations (NGOs) working in health related
projects within the counties have been incorporated in the membership of
these PBF scaling up committees under the county governments. It is
anticipated that this mix of politicians, NGOs, civil society representatives
and civil servants in the various committees set up within the county
government will further strengthen accountability in the way resources for
the PBF scaling up are utilized. The stakeholders argued that for PBF to
succeed, there must be staff, the required chemicals or reagents,
medicine and money for maintenance within the health facilities.
53
d) Activated Community Health Strategy
One of the recent achievements of the county governments is that they
have employed additional health workers and also for the first time
recruited Community Health Workers into a regular government payroll.
Interviewees during this study argued that this action would lay a better
foundation for the scaling up of PBF. Evidence from this study shows that
involvement of community members has improved health outcomes in the
Samburu piloting of PBF. Subsequent design for the scaling up of PBF in
Kenya has also embraced the involvement of Community Health Workers
as part of the team for scaling up PBF and benefit from the accruing
incentives as can be shown from the following interview session with one
of the stakeholders;
……So in your planning have you thought of this community health
units playing a role in scaling up of …..
……Very much that is where we are focusing. It was just recently
when the county public service board recruited health care workers
and even the community health workers were included so that the
community level is targeted fully….. (Interview,14)
Thus, the identified role of community health units under the community
health strategy in scaling up of PBF is considered as the cornerstone for
the success of the scaling of the PBF. In fact, some of these community
health units had been capacity built by other partners as was reported in
some of the counties earmarked in the first phase of scaling up of PBF.
Informants in this study explained that the devolved system of
governance would provide them with an opportunity to activate the
community health strategy through requesting for the engagement of
Community Health Workers (CHW) in their Annual Health Plans (AHPs) for
the scaling up of PBF. This approach for the activation of the community
health strategy is based on the lessons learnt from the Samburu pilot in
which it was observed that PBF had brought the community members as
54
an important stakeholder in the performance of health facilities. The
stakeholders at the county level argued that it has become easier to
engage the community health workers through budgetary provision of the
county government. These community health workers would enhance
service delivery and the realisation of the indicators under the
Performance Based Financing (PBF). One of the informants thus
explained:
…….right now we have recruited what we call community health
assistants (workers), we want to actually strengthen our
communities strategy in xxxx to actually improve some of these
indicators and once we actually engage these community health
assistants even for them they have tools and they have indicators
we want them to be responsible for certain families. So if you are a
health worker and you are responsible for family A and their health
indicators are improving as per the data which we are filling in the
DHIS, then you might actually be able to reward this person either
through giving them incentives, incentives is a very good way of
encouraging these people to actually perform………(Interview, 13).
Involvement of Community Health Workers (CHWs) has been incorporated
in the current design of the scaling up of PBF. This has been necessitated
by the best practices that were learnt during the evaluation of the
Samburu PBF pilot. This was clearly explained in the following verbatim
quotation from one of the informants:
…………One critical point that came out was the involvement of CHWs
and the recommendations that came out pointed to the involvement
of CHWs that was very key. Even the providers were saying that
their should be a way of ensuring that they are brought on board
through those funds because they were an important link between
the facility and the community and they were also incentivized using
the 60%. Because they were able to trace defaulters in the case of
55
babies who were up for vaccinations they were able to go to the
community and bring them……(Interview, 21)
Involvement of Community Health Workers will not only provide an
effective linkage between the communities and the health facilities within
their catchment areas but will stimulate the demand side aspect of health
deliveries, through defaulter tracing for the immunization programs, HIV
and AIDS testing programmes and other community outreach health
promotion programs. It is anticipated that these programs initiated under
the devolved health units will effectively feed into the current design for
PBF and contribute to successful scaling in Kenya. The following interview
excerp clearly illustrates this argument:
I(2): So they were used for demand creation….
R: Yes demand creation… but also the outreach services improved a
lot because of these funds because facilities could afford fuel for
transportation to go and take services to the community as well as
provide for their lunches as they go to the outreaches. (Interview,
17)
It is anticipated that the demand created as a result of the outreach
services performed by the Community Health workers will provide an
improved framework through which the health facilities could realise the
target for the PBF indicators. The community health workers or volunteers
who are now being engaged by the county governments will help to
address the problem of increased workload being faced by the health
workers in the PBF facilities. This would enable the health workers to
provide quality health services and achieve the targeted quantitative and
qualitative PBF indicators. The interviewees therefore further explained
that the devolved health provision system would contribute to the
successful scaling up of PBF if the community health strategy is properly
activated.
56
However, it is not clear in the current design of PBF scaling up how other
demand aspects of health outcome indicators associated with the pilot
have been incorporated in the design of the scaling up of PBF. One such
outcome of the PBF that was not anticipated is the incentives given to the
mothers to deliver in the health facilities as a way of influencing patient’s
behaviour towards improvement of health outcomes. There is evidence
from the lessons learnt in the Samburu piloting that some Health Facilities
Management Committees (HFMCs) incentivised mothers who gave birth in
the health facilities as a mechanism to encourage more mothers to deliver
in the health facilities through the use of the resources available in the
health facilities such as the funds from PBF and HSSF funds. The
experience is that more mothers came to deliver in the hospitals and
enhanced the chances of the facilities to receive higher incentive figures.
This is clearly illustrated in the following interview excerp:
I2: How about the mothers themselves.
R: for the mothers who come to deliver in our facilities, this is
through our own initiative…
I: Using PBF money
R: Yes using PBF money and HSSF funds…we are able to buy some
incentives like we buy them bar soap and lesos and that only
happens if the mother delivered in the facility and the child is
notified in this register and is well documented in the facility
register. They feel so comfortable……………(Interview, 17)
There is no evidence that incentives aimed at influencing patients’
behaviour to change their health seeking behaviours to improve health
outcomes through creation of demand has been incorporated in the
Kenyan PBF scaling up design. Other activities that were identified to
stimulate demand for PBF based indicators include the outreach programs
57
through the use of Community Health Workers and has been incorporated
in the scale up design.
4.2.3) Devolution as a barrier to scaling up of PBF
There were views obtained in this study which were of the opinion that
whereas devolution can be an enabler in the scaling up of PBF in Kenya, it
can also pose barriers. The reasons given to explain why devolution might
be considered as a barrier to the successful scaling up of PBF included;
the anticipated problems of drug stock out and Systemic Problems. This
section presents data on these two main reasons considered as barriers to
successful scaling up of PBF.
b) Anticipated problems of drug and supplies stock out
Stakeholders have argued that there is a possibility of drug stock and
supplies stock out due to lack of a centralized drug and medical supplies
procurement system. They further argued that some county governments
are not keen to purchase drugs directly from the authorized medical
suppliers –Kenya Medical Supplies Agency (KEMSA). It can be argued that
such an arrangement would allow the county governments to look for
supplies wherever they are available to help address the problem of drug
stock outs. On the contrary, such an arrangement can possibly lead to the
counties resorting to purchasing counterfeit drugs which can compromise
the quality drugs supplied and eventually the quality of health services.. It
was argued that the issue of drug stock out derailed progress during the
piloting of Samburu PBF when the drugs and other supplies were centrally
procured by the national government and distributed to the health
facilities countrywide. It is anticipated that the problem could be worse
with the county governments as was explained by one of the informants:
……….Yes the stock out may be worse now in the devolved system
because there is no centralized sourcing for drugs. Even when we
had centralized sourcing like in the Samburu pilot we still had stock
58
out that’s why am saying that it may be worse now because of the
interest people have….and I don’t want to call it corruption but it
was easier to procure non pharms and drugs from the national level.
Kemsa has been allowed to enter into some agreement with the
county governments but some of them am told are avoiding coming
all the way to Nairobi they are doing business at the local
level…..(Interview,6).
The above argument is bolstered by an earlier explanation by the
stakeholders that the political elites at the county level might not prioritize
the purchase of supplies for vaccination or HIV testing kits because they
do not believe in statistics which cannot be used for political campaigns.
This argument is related to an explanation by one of the stakeholders who
averred that most countries that have devolved healthcare services have
retained the purchase of certain medical supplies as national goods.
……..most countries what they do is procure these goods as national
products goods…and then give in kind to the sub national entities
that is the standard practice in all countries with devolved
governments…….
….... Also any country devolved system, the responsibility to core
public health functions was retained at a central point. Like take a
case of cholera outbreak or there’s an ebola outbreak….who takes
responsibility is it the central government or the county? Then
vaccines who will procure vaccines who will procure HIV packs all
these monies have gone to counties which we are only hearing
promises but not action. Without those in place how can RBF
work……?
………..without vaccines, without TB medicines without HIV testing
kits how can RBF work………….. (Interview,6)
59
It has been argued that the success of PBF scaling up cannot succeed if
the devolved system does not prioritize the purchase of supplies for
vaccination, HIV and AIDS testing kits.
Some of the stakeholders are arguing that the county governments would
not want to procure the required vaccines and HIV testing kits because
they are in a political rush to please their voters by investing in visible
infrastructure. The stakeholders argued in most countries with the
devolved system of governance, vaccines and HIV testing kits are
procured as national products goods and then given in kind to the sub
national entities for use in the provision of services. There were fears that
the immunization services are already destabilized because the vaccines
are fast running out in the counties.
……..Exactly already the services are on life support now so because
vaccines are running out of stock and the equipment needs
replacement…...(Interview, 6)
Situations such as the one explained by a key informant above has the
potential to derail the successful implementation of the scaling up of PBF
in Kenya. This underscores the need for change in the political culture of
the Kenyan politicians to embrace political significance not only in the
physical structures but also in such non-physically visible improvements in
health indicators as a political campaign tool.
ii) Structural Problems
Several barriers related to structural problems. These problems include
inadequate capacity of the PBF scaling up team to handle the problems
related to elite capture during the implementation of PBF. Interviews with
various stakeholders particularly at the county level showed that there
would be a likelihood of politicians influencing the process of
implementation to favour their political motives. The stakeholders at the
county level for instance explained how the politicians, particularly the
60
Members of the County Assemblies (MCAs) have been ordering the health
facility in-charges to release the ambulances to transfer their relatives or
friends to hospitals without adhering to the laid down procedures. The
health workers respect such orders because the MCAs are their employers
within the county governments and disobeying their orders would put
jeorpadize their employments. They further complained that the MCAs are
likely to use their political power to influence the choice of health facilities
to be included in the PBF scaling up without necessary following the
guidelines for choosing such facilities.
Lack of consistency in the training of health workers or the
implementation team from the counties was also cited as one of the
problems that are likely to negatively influence the scaling up process of
PBF. They argued that the selection of health workers to be trained in PBF
is not consistent because different people are selected in different training
days thus leading to lack of continuity in the training. This problem was
also related to the problem of frequent transfers of staff in charge of PBF
program both at the Ministry of Health headquarters and at the county
levels. These transfers disrupt the implementation process of the PBF
scaling up.
4.3 Political Economy considerations of the scaling up of PBF
4.3.1 Introduction
Despite the fact that political economy matters are already in-built in the
entire scaling up of PBF, there are certain outstanding issues in the politics
of scaling up PBF that are worth singling out. They include; the need to
obtain political buy-in and how the general political aspirations might
affect the scaling up of PBF.
61
4.3.2 The need to obtain political buy-in
Initial political buy-in during the piloting of PBF in Samburu has been
identified as one of the best practices obtained that have now been
incorporated in the scaling up process. It was realized during the piloting
that initial political buy-in of the PBF idea contributed to better
performance of health facilities. The political buy-in was initiated through
the discussions with the elected political elites in the sub-county who went
round the villages through organized community outreach programs
aimed at explaining to the community members the importance of utilizing
the services being offered under the PBF pilot. There were initial
resistance for the utilization of other services under the PBF indicators at
the pilot such as Family Planning services due to religious beliefs and the
informants explained that this problem was solved when the elected
political class in the sub-county was involved in the PBF piloting activities.
Consequently, the involvement of the political class contributed to the
increased demand for the services under PBF piloting.
Interviews with the various stakeholders indicated that the design of
scaling up PBF in Kenya is currently considering the involvement of the
political class at the county level to ensure budgetary support for the
integration of PBF into the county budgeting process through the Annual
Health Plans (AHPs) and the County Integrated Development Plans
(CIDPs) which are the budgetary supporting documents at the county
levels. Stakeholders have emphasized the need to properly conduct
advocacy to enable the political class in the counties to appreciate the
concept of PBF. They argued that such an appreciation would enable the
budgetary proposals for PBF to sail through in the county assemblies. The
need for proper advocacy among the political class is further necessitated
by the fact that the health docket consumes the biggest percentage of the
county budget. Raising the health budget beyond the current levels
therefore requires proper advocacy to the political class to convince them
62
that there would be noticeable impact on the communities if the
budgetary proposals to support PBF are passed. One of the informants
during the interviews thus explained:
………. without clear advocacy or serious advocacy for them to have a
good buy-in, it would be a threat because one would say why do we
need to vote for money as already voted for items, so if they don’t
have a clear understanding on the concept it will be a threat, however,
if really the concept is advocated for and they appreciate that the RBF
would even promote the retention of health workers in those areas the
RBF also will contribute to attraction of persons to places they didn’t
want to go and work, then it would be an opportunity……...
………….So when it comes to appropriation of funds during the county
assembly budgeting forum then they will be able to say yes we are
setting aside probably 60 million shillings under results based finance
system for sustainability because we have seen the results somebody
working in a remote area would not want to come out because they are
motivated in one way or the other………….(Interview,11).
One of the key advocacy messages would be to convince the political class
that PBF would help to retain health workers particularly in those hardship
areas such as in the Arid and Semi-Arid Lands (ASAL) which traditionally
are considered not good to live in by workers from other Kenyan regions.
Most workers from other Kenyan regions posted to work in ASAL regions
consider their posting as a punishment and spend most of their time at
the Ministry headquarters to influence their transfers from such places,
thus leading to high rates of absenteeism and poor service
delivery.Lessons from the Samburu pilot have shown that PBF has
changed the attitude of many health workers in Samburu central which is
in ASAL regions and that the health workers are nolonger asking for
transfers, working longer hours and even forfeiting their leave days to
63
produce better outcome indicators and receive higher incentives. One of
the stakeholders thus explained during the interviews:
………One other thing that was beneficial was that the request for
transfers of workers within and out of Samburu reduced. Because they
felt that their work was being recognized based on their
performance…….(Interview,5)
The stakeholders who were interviewed at county level explained that
they intend to use the improved health outcomes as a result of PBF to
advocate for acceptability of PBF for the budgeting and sustainability into
the future after the donor funding has closed. Such advocacy is aimed at
influencing the decisions made with regard to the budgeting of health
services so that PBF becomes part of the budgeting process as explained
by one of the stakeholders during the interview:
…………I think they have to make decisions based on work plans and the
budget because the process that you understand is that the facilities at
that level do their work plans then they forward it up then there is a
big budget which is taken to the assembly for approval. So that process
must be well managed and advocacy well done to make sure that once
it reaches that level these people know exactly if its PBF what it
means…..Because they could end up reducing monies for some of these
initiatives that are very critical in improving
outcomes………..(Interview,14)
Lack of political buy-in can be a barrier to successful scale up and
institutionalisation of PBF in the Kenyan healthcare expenditure in order
for the project to attain sustainability.
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4.3.3 Effects of political aspirations on PBF scale up
There was a general fear among the stakeholders particularly at the
county level that the political behaviour of many politicians to spend public
resources on projects of political significance –those that are visible to the
voters might derail the inclusion of PBF funds in the county budgets. They
argued that politicians would like to spend public funds on projects that
have greater implications for their future campaigns and political power.
This argument by the PBF stakeholders at the county level resonates well
with an argument by one of the main donors in the PBF that the county
governments might not be able to spend county funds on products of
national good such as vaccines and testing kits on which PBF is anchored.
Due to this political behaviour, the stakeholders at the county level
explained the difficulties they undergo to convince the political class on
the health outcomes through their presentation of statistics that the
county politicians are not interested in because it is difficult to use such
statistics for political campaigns. One of the stakeholders thus explained:
…and even there are times you go and present statistics and they listen
but they do not even understand them. We say we are trying to keep
the HIV prevalence down there they will listen but they will not be able
to use this statistics to campaign with. Some of the MCAs understand
while others will be happy to say during my tenure, I constructed a
facility without knowing its just a structure without service provider
which is the most important thing…….(Interview,12)
The stakeholders during the interviews therefore argued that for PBF to be
sustainably institutionalised within the Kenyan health care system, there
is a need for higher political ranks to be convinced before other health
workers at the lower level to be trained and made to understand the
concept of PBF. One of the informants thus explained:
……….now if RBF was like to happen like tomorrow, I would
recommend that the process starts from up bottom, we train the
65
politicians, we train the implementers that is now the health care
workers at the county level, we train the health workers at the sub
county level, we train all the health workers themselves who are
hands on to understand the concept……..(Interview, 20)
On the contrary to this view, the scaling up of the PBF in Kenya started by
targeting technocrats at the Ministry of Health headquarters for capacity
building and only involved the political ranks at the county level after the
development of the manual and training of the implementers at the
county level. The political class within the counties including the council of
governors were only involved in one of the sensitization meetings. The
interviews conducted during this study did not show any evidence that
other lower cadres of the county political class such as the Members of the
County Assembly (MCAs) have been fully involved and convinced of the
significance of allocating public funds to institutionalize PBF within the
county health care financing. The approval of all the workplans and
budgets to be implemented by the county governments are debated and
approved by the county assemblies. The stakeholders further argued that
the MCAs have got the ability to exert political pressure and in terms of
resource allocation, they can influence resources to be taken to an area
which is not a priority and they can also decide what they want to be the
priority.
5.0 DISCUSSIONS
This report has shown the process through which the ideas and knowledge
of performance-based financing has been introduced in Kenya at the
international training in Mombasa which was spearheaded by the World
Bank and the Netherlands government. The meeting was attended by
representatives from countries that are implementing performance-based
financing. The World Bank and the Netherlands government are therefore
66
the main actors in the process of transitioning PBF ideas and knowledge
transfer and sharing of experiences from different countries that are
implementing PBF. An important outcome of this sharing experiences of
implementing and scaling up of PBF in different countries was the PBF
implementation manual that was based on the international experiences
but had to be domesticated to the Kenyan context. Data obtained in this
study shows that the Kenyan government through the Ministry of Health
with technical assistance from the World Bank spearheaded the
domestication of PBF agenda through the revision of the scaling up of PBF
manual and training as well as assisting the county governments to
implement the scaling up of PBF at the sub-national level. The World Bank
(funding and providing technical support) and the Kenyan Ministry of
Health (regulator) has continued to play a key role in the scaling up of PBF
with the county governments being involved in the scaling up process to
pave way for the integration of the PBF within the Kenyan national health
system. Non-state actors such as the Aphia-Plus which is a US-Aid project
have been identified and formerly included in the scaling up manual as
independent verifier. Verification was identified as a problem during the
piloting of PBF due to the fact that the position and the duties of the
verifier were not properly grounded in the manual and the verifier only
visited the health facilities upon invitation by the Ministry of Health. This
practice undermined the role of independent verification as it is the
practice in other countries where PBF has been implemented Savedoff
[28].
The analysis of data obtained in this study is guided by the notion of
health policy triangle which takes into consideration the process, context,
and actors who interact to produce content within the policy reform (see
Walt and Gilson, 1994). This concept advocates for the analysis of policy
reform by focusing on interactions among actors in the international,
national and sub-national levels in the process of developing and
implementing health policy. In the Kenyan case, the newly devolved
67
county governments form the sub-national levels within which PBF scaling
up and integration within the healthcare financing system is performed.
The Kenyan context within which PBF is being scaled up is partly anchored
on Health Sector Reforms (HSR) that have taken place around the globe
within which Performance Based Financing is being implemented. Bhatia
and Rifkins [24] have argued that policies of Health Sector Reforms (HSR)
around the globe have weakened the role of state and reduced its capacity
to achieve objectives of improving health. Furthermore, Kenya has
adopted the community health strategy which recognizes the role of
community participation by lay people in health improvements among
population. Furthermore, Bhatia and Rifkins [24] argue from their review
of Primary health care that there is evidence across several countries to
show that involvement of lay people in health care provision can improve
health among populations. This finding from their review is supported by
the analysis of the interviews conducted in this study which showed that
facilities that involved the community health workers reported better
health outcomes than those which did not. This lesson from the PBF pilot
has formed the basis for designing the scaling up of PBF in Kenya.
Savedoff [28] explains that the emphasis on delivery of services and the
poor track record of many aid programs have generated interest in
explicitly using incentives in developing programs, not only to improve
efficiency and sustainability but also to encourage innovation and promote
behavioural changes. Consequently, Performance-Based Financing (PBF)
or Results-Based Financing (RBF) is among a range of incentive programs
being debated today around the globe and emphasize two particular
dimensions namely; the agent whose behavior the incentive seeks to
change and the specificity of the output or outcome measure.
Performance-Based Financing has also followed on the wave of
development programs that utilize incentives based on the idea of
principal-agent relationships where the actors are the funders and
68
recipients who are often in different countries and respond to entirely
different constituencies.
There is evidence that the Kenyan PBF is being implemented within a
background of earlier interventions in other sectors through cash
transfers, direct transfer of funds to the schools as a government strategy
to enhance school enrolment through free schooling policy. In addition,
there are other related interventions in the health sector such as the
Danida’s Direct Facility Funding (DFF) which provided the framework for
the countrywide establishment of the Health Sector Services Fund (HSSF)
[30]. This Health Sector Services Fund (HSSF) laid the ground upon which
the piloting of PBF in Samburu Central was performed. However, the
Danida which is the sole sponsor of HSSF in Kenya did not either
participate in the PBF piloting and the scaling up due to doubts regarding
the authenticity of the PBF programs to particularly pay for incentives that
accrue from the PBF activities.
There has been serious doubts of the effectiveness of the verification
system to prevent wastage of resources through either double payments
or failing to capture problems related to gaming that are also reported in
other PBF studies. Whereas the Kenyan study shows that there are serious
doubts regarding the effectiveness of the verification system, a Rwandan
study on the contrary found lower levels of false reporting of less than 5%
in their tracking survey of about 1000 patients. However, Savedoff [28]
has explained that verification of information is a difficult task in PBF
implementation and like any other incentive program can be gamed. The
author further argues that paying recipients for self-reported progress
creates a strong temptation to exaggerate performance. Other studies
such as Lagarde et al. [27], Bonfrer et al. [26] have also emphasised the
need for provision of accurate data that will avoid gaming and ensure that
the program is credible. In this study, lack of credibility or doubts raised
69
when the figures for PBF pilot were presented contributed to delayed
disbursements of the incentives.
Based on the Kenyan experience of piloting PBF in Samburu where the
Health Sector Services Fund (HSSF) and Output-Based-Aid for maternal
health through Safe motherhood vouchers were being implemented raised
doubts as to whether the outcome indicators for which incentives were
paid were only as a result of PBF piloting. There were examples from the
interviews with facility in-charges in Samburu during this study which
showed that funds from either PBF pilot or HSSF were used to incentivise
mothers to come to deliver in the health facilities. There was suggestion
that it is only through electronic verification that a program can be sure
for which services the incentives are being paid. A Burundian study on the
introduction of performance-based financing with associated
improvements in care and quality has demonstrated the effectiveness of
the use of a difference-in-difference approach to identify the effects of
performance-based financing on the use and quality of health services in
contexts such as the Samburu pilot (see Bonfrer et al. [25], [26]). An
evaluation of PBF piloting in Samburu on which the scaling up of PBF in
Kenya is based has not however discussed much about the use of a
difference-in-difference strategy in identifying the effects of PBF on the
earmarked outcomes. Furthermore, it is not clear from the evaluation
whether the quality indicators reported were solely attributable to the
effects of the resources derived from the 40% facility incentives or other
resources such as those from the HSSF and safe motherhood vouchers
could be partly ploughed back to improve the qualitative indicators in the
facilities. Perhaps, it would be a worthwhile idea to try the difference-in-
difference approach in future when evaluating the impact of PBF program
in Kenya and other settings where the program has been implemented.
Some health facilities in Samburu innovatively utilized some of the funds
to incentivise mothers to encourage them to deliver in the health facilities.
70
This is one of the innovations that is advocated for in recent literature on
PBF but which seemingly is not evident in the design of the Kenyan PBF.
For instance, Basinga et al. [23] argue that PBF programs should not only
incentivise health care providers but also provide financial incentives
directly to the patients as a mechanism to influence patient’s care seeking
behaviour. Data obtained from one of the model health facilities under PBF
program in Samburu showed that incentivising mothers coming to deliver
in the health facilities comparatively improved the outcome indicators in
that facility as compared to others under the same program which did not
incentivise mothers.
This study identified several enablers and barriers to the efforts of scaling
up PBF in Kenya within the devolved governance and the devolved
healthcare system. Devolution of governance in general and specifically
devolution of health services was to a large extent considered an enabling
factor in the scaling up of PBF in Kenya. This is because devolution has
enhanced autonomy through localised decision-making processes. This is
because the devolved governance has created better opportunities in
which decisions reflecting the local realities are made. The stakeholders
explained that at a more general level, decisions made under the devolved
system have led to an improvement in infrastructure such as the
expansion or construction of new maternity wards, provision of electricity
to enable deliveries to be conducted at night and the purchase of
ambulances that are used to provide refferral services. They also
explained that devolution has helped to strengthen accountability to the
local voters in relation to the decisions made which include health
services. Accountability was also discussed in relation to changes in
behaviour of the health workers and health system organization to
become more responsive to the communities through a staff audit,
monitoring of health workers. This has drastically reduced the high rates
of abseeintism and wastage that had been experienced under the national
government (see also Witter et al. [29]). Infrastructural improvement
71
within the health facilities would help to improve quality of services for
PBF which is assessed as one of the process indicators besides availability
of equipments, correct and up to date registries and prescription
behaviour.
Another significant enabler of the scaling up of PBF is the ability of the
county governments to procure the services of Community health workers
(CHWs) who are helping not only to provide the linkage between the
communities and the health facilities through outreach services but also
helping in performing other administrative and clerical duties at the health
facilities and free the health workers who would otherwise be overworked
to concentrate in provision of health services. The idea to involve these
community health workers in the scaling up of PBF in Kenya is based on
the lessons learnt in the piloting phase where stakeholders argued that
health facilities which involved community health workers in the PBF
incentive sharing reportedly performed much better than the facilities that
did not involve them. These community health workers now become
active actors not only in the scaling up of PBF but also contributed to
systemic changes in the overall Kenyan healthcare system.
The Kenyan health system relies on the services of community
healthworkers at the level one of healthcare system under the Community
Health Strategy policy. However, since the introduction of the policy, the
national government has not included the healthworkers in the planning
and budgeting for the healthcare services. Stakeholders at the county
levels reported that they are now including the services of the community
health workers in the County Annual Health Plans (AHPs) which will feed
into the overall County Integrated Development Plan (CIDPs). CIDPs are
the budgeting tools for the county governments and are approved at the
county assemblies after undergoing scrutiny at the county assembly
health committee.
72
In Rwanda, Basinga et al. [23] have explained how the partnership
between health providers and community health workers promoted
institutional deliveries under P4P scheme. Their study did not however
discuss whether the Rwandan community health workers benefited from
the incentives as is the case with the Kenyan case. One of the suggestions
in their study to promote institutional deliveries through influencing
patients’ health seeking behaviours is to give Community health workers
an incentive to identify patients and encourage them to visit clinics. A
Burundian study on the effects of performance incentives on the utilization
and quality of maternal and child care underscores the need for the health
system or the provider to change patients’ utilization choices Bonfrer et al.
[26], see also [27]. Furthermore, [27] has raised questions regarding the
need to limit additional administrative burden on providers due to the
effects of Payment for Performance so as to ensure quality services. But
the need to find mechanisms to target the poor and vulnerable
populations to benefit from P4P programs to improve equity and cost-
effectiveness has also become an issue in emerging literature on P4P
programs.
Based on the experiences of the Samburu pilot and the views of Kenyan
stakeholders in the scaling up of PBF, it becomes plausible to argue that
the involvement of community health volunteers can be a possible
mechanism to enhance targeting so that P4P programs can be widely
accessed by the poor and they can be sensitized through community
outreach programs and the involvement of community health workers.
This argument is supported by ideas by [29] who explain that equity is
one of the objective of the PBF and this can be achieved by improving
both coverage rates and equity of outcomes by encouraging expansion of
services to hard to reach groups.
There are views in this study to show that the devolution of governance
structures and more particularly the devolution of health services could be
73
barriers to the process of scaling up PBF. Two explanations were given
namely; lack of inter-governmental co-ordination and the anticipated
cases of drug and supplies stock out.
One of the outstanding issues with regard to the perception of devolution
as a possible barrier to successful scaling up of PBF is the fact that the
politicians who are the main PBF actors at the county level might find it
politically insignificant to invest devolved funds in projects that are difficult
to market them during campaigns. There has been concern that vaccines
and HIV testing kits that some technocrats in PBF have classified as
national products or goods of national value ought to be bought by the
national government and distributed to county governments. These
technocrats have complained that the county governments have not
bought vaccines and HIV testing kits thus rendering immunization
program ineffective. PBF stakeholders at the county level also expressed
concern regarding their inability to convince the political class to
appreciate the improved health outcomes that are presented in form of
statistics such as immunization levels, reduced HIV rates and other health
outcomes expressed in statistics. These are contrasted with the more
visible and politically significant projects such as the expanded or newly
constructed maternity wards, sunk boreholes, constructed roads,
ambulances purchased and other visible projects which are relevant for
political campaigns. This political behaviour at the county level has been
considered as a barrier to successful scaling up of PBF and integration into
the health system.
Thus, political economy considerations of the PBF scaling up have the
potential to either enable or hinder the integration of PBF into the Kenyan
healthcare financing system. Stakeholders at the county level expressed
the need to involve the county governments at the earliest stages to for
political buy-in and budgetary support. There has been an argument
across the counties where data for this study was collected to the effect
74
that improved health indicators would be the selling point to enable the
county governments accept to allocate resources for PBF within their
budgets. This would effectively happen if the politicians and the newly
devolved institutions at the county level such as the county assemblies
appreciate the health statistics and vote for PBF funds in their budget.
This underscores the need for advocacy efforts to convince the local
political class to allocate funds for PBF so that the program is sustainable
and move away from total dependency on donor funding. The significance
of political interest in and commitment to PBF has been underscored in a
study by Witter et. al. [29]. They have argued that political commitment is
critical whether it is seen as consistent with or contrary to national
priorities in relation to health worker retention schemes, decentralization
or different approaches to extending health coverage which is evident in
this study.
In Kenya, the actors at the government level are yet to allocate funds
specifically for PBF. Some of the stakeholders at the county level lamented
that the Kenyan integration of PBF into the national or county government
health care financing is slow as compared to other countries where PBF
has been or is being implemented. In Burundi, [26] have explained that
the Ministry of Health incorporated payment for maternal and child health
services into the performance-based financing scheme. Fifty-two percent
of the total funding for performance-based financing is provided by the
Burundi’s government, 28% by the World Bank and the remaining 20%
from other donors. In Kenya, the World Bank has initiated the opening of
a special fund account in the counties for the implementation of PBF and
have allocated USD 20 million for the scaling up. Contrary to the
Burundian case, there is no evidence that either the government or any
other donor has pledged to provide funding to this special account.
Conversely,there are several interventions in Kenya that are currently
implementing programs within the health sector such as the Health Sector
Services Fund (HSSF) funded by Danida, Safe Motherhood maternity
75
voucher system funded by the German Development Bank (KfW) and the
free maternity services in public health facilities funded by the Kenyan
government. In addition to these, there is the beyond zero campaign for
maternity health spearheaded by the Kenyan first lady. However, there is
no study in Kenya that has clearly explained the cost-effectiveness of
these different interventions aiming at improving maternal and child
health and other primary health services. The findings of such studies
might help to come up with suggestions on how to effectively spend the
resources that are now scattered in different interventions and ensure
equitable access to maternal and child health services for poor and
vulnerable women of reproductive age. Such studies in Kenya would also
shed light on whether and if possible how the Burundian PBF can be
replicated in the Kenyan context since there is already a special PBF fund
in the counties created through technical support from the World Bank
where interested actors can channel their funds for the nationwide scaling
up of PBF. Furthermore, [26] has suggested the need to conduct more
research into the cost-effectiveness of PBF and how best to target
vulnerable populations to benefit from such a program.
6.0 Conclusions and Recommendations
6.1 Conclusions
The process of scaling up PBF in Kenya from a pilot scheme to a
healthcare system has been influenced by several factors including the
international debate and efforts towards Universal Health Coverage (UHC),
the need to meet Millennium Development Goals (MDGs) related to
improvement of Maternal and Child Health (MCH) indicators, HIV and
AIDS reduction. Further efforts at the International scene to enhance
equity in access to health services for the poor and vulnerable segments
of the World populations and experiences of piloting and implementing
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PBF in the national health care system also influenced PBF piloting and
scaling up in Kenya. The Kenyan PBF is also triggered by the fact that
Kenya has one of the highest manpower skills among the developing
countries which does not correspond to the huge service gap experienced
in healthcare provision. This led the international and national
development partners to pilot and eventually scale up PBF as a
mechanism to incentivise the already highly trained healthcare workforce.
This process has been influenced by a number of actors who are classified
as development partners and the local partners. The World Bank has led
the efforts by the development partners to provide technical and financial
support while earlier efforts by Danida in Health Sector Reforms (HSR)
through the Health Sector Services Fund (HSSF) provided anchorage point
for PBF piloting and scaling up.
The local context that has informed the process of piloting PBF in Kenya
has included; the earlier social protection approaches to the expansion of
access to primary and day secondary education through direct transfers to
schools which opened their own accounts. This was followed by the Direct
Facility Funding (DFF) within the Healthcare in which all health facilities
opened their own accounts through which the donors channelled funds like
was the case with HSSF which directly transferred funds to all primary
health facilities in Kenya. The experiences and outcomes of these direct
cash transfers to the schools and health facilities as well as the lessons
learnt from the piloting of PBF in Samburu central have laid the basis for
scaling up PBF in Kenya.
Difficulties in verification of the payments has been identified as one of the
most difficult task in the implementation process of PBF based on the
experiences from Samburu pilot. The difficulties in verification and the fact
that there re several interventions targeting improvements in the same
indicators as PBF has raised doubts among some actors as to the cost-
effectiveness of the PBF program in relation to other interventions aimed
77
at improving the overall health system performance and particularly the
indicators under PBF. Furthermore, there is evidence that health facilities
management committees which had PBF and other interventions used
funds to influence health seeking behaviours of pregnant women to attend
ANC and deliver in the hospitals through provision of incentives to the
mothers who have delivered in the health facilities and community
outreach programs that are organised in partnership with Community
Health Workers (CHWs). Such health facilities reported better PBF
outcome indicators than those which only incentivised health workers an
indication that a partnership between health facilities and community
healthworkers in PBF can influence health seeking behaviour of patients
and improve health system performance.
The institutional arrangements under the devolved governance and
particularly under the devolved health system has more enabling factors
to the scaling up of PBF in Kenya as compared to identified barriers.
Enabling factors include; the fact that decisions to allocate resources and
prioritize have been decentralised to the local political class and other
actors at the county governments. These localised decisions have
contributed to improvement in infrastructure within health facilities,
enhanced accountability in terms of decisions made regarding allocation of
resources and human resource management which has eliminated high
rates of staff abseeteeism and the activation of the community health
units which had remained inactive due to lack of funding from the county
governments. These factors have been identified as enablers in the scaling
up of PBF in Kenya. On the other hand, barriers to PBF scaling up have
been identified as; lack of an intergovernmental co-ordinating mechanism
and the fact that certain dockets such as social protection and the national
health insurance have not been devolved is likely to create complications
they have a direct relationship with attainment of PBF indicators. Another
barrier to PBF scaling up has been identified as anticipated drugs and
other supplies stock out, particularly the vaccines and HIV testing kits
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which most stakeholders have complained that the political establishment
at the county levels are not ready to spend resources in what are known
as products of national goods due to the fact that the statistics that
emanate from services in which such products are consumed cannot
provide a platform for political campaigns as compared to investing funds
in projects that are visible to the local voters.
Political actors have a significant influence in the integration of PBF in the
healthcare financing system at the county level through approvals in the
newly established county assemblies. However, this can only be achieved
if the initial political buy-in is achieved at the beginning of the design and
implementation of PBF program. Evidence obtained in this study show that
political commitment is critical for the integration of PBF in healthcare
system through approvals in the Annual Health Plans (AHPs) and the
County Integrated Development Plans (CIDPs).
6.2 Recommendations
1. There is a need to address the doubts emerging from the difficulties
associated with verification of the payments of the PBF incentives and
ensure that the cost effectiveness of PBF in relation to other interventions
is clearly explained in order to enhance equitable access to health services
by the poor and vulnerable populations.
2. Future design of PBF should include partnership with the communities
to enhance access to basic health services to the poor and vulnerable
populations through community outreach programs and influence health
seeking behaviours of patients in order to improve health outcomes under
PBF.
3.There is a need to involve the political class in the initial design of PBF in
order to obtain the initial political buy-in for sustainability through
budgetary approvals for the integration into the healthcare system at the
county level
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6.2.1 Recommendation for further research
1. Further research should be conducted to establish the cost-
effectiveness of the various interventions in Kenya aimed at enhancing
quality services for maternal and child health and investigate the
possibilities of merging the programs under PBF as is the case in Burundi.
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7.0 References
1. Bossert T: Analyzing the decentralization of health systems
in developing countries: decision space, innovation and
performance. Soc Sci Med 1998, 47(10):1513-1527.
2. Soeters R, Habineza C, Peerenboom PB: Performance-based
financing and changing the district health system: experience
from Rwanda. Bull World Health Organ 2006, 84(11):884-
889.
3. Ssengooba F, McPake B, Palmer N: Why performance-based
contracting failed in Uganda--an "open-box" evaluation of a
complex health system intervention. Soc Sci Med, 75(2):377-
383.
4. Basinga P, Gertler, P.J., Binagwaho, A., Soucat, A,L.B, Sturdy,
J.R and Vermeersch, C.M.J Paying Primary Health Care
Centres for Performance in Rwanda. Policy Research Working
Paper. In: The World Bank. 2010.
5. Fritsche G SR MB: Performance-Based Financing Toolkit. In.
Washington, DC: The World Bank; 2014.
6. Fox S, Witter S, Wylde E, Mafuta E, Lievens T: Paying health
workers for performance in a fragmented, fragile state:
reflections from Katanga Province, Democratic Republic of
Congo. Health Policy Plan, 29(1):96-105.
7. Ir P, Bigdeli, M., Meessen, B., & Van Damme, W.: Translating
knowledge into policy and action to promote health equity:
The Health Equity Fund policy process in Cambodia 2000-
2008. Health policy,2014 2014, 96(3): 200-209.
8. Hartmann A LJ: Scaling up: a framework and lessons for
development and effectiveness from literature and practices.
In. Washington DC: Wolfensohn Center for Development, The
Brookings Global Economy and Development; 2008.
81
9. Nine steps for developing a scaling up strategy. Geneva:
WHO/ExpandNet; 2010.
10. Fritsche G SR, Meessen B: Performance-Based Financing
Toolkit. In. Washington, DC: The World Bank; 2014.
11. Bertone MP, Meessen B: Studying the link between
institutions and health system performance: a framework
and an illustration with the analysis of two performance-
based financing schemes in Burundi. Health policy and
planning 2013, 28(8):847-857.
12. Meessen B, Soucat A, Sekabaraga C: Performance-based
financing: just a donor fad or a catalyst towards
comprehensive health-care reform? Bulletin of the World
Health Organization 2011, 89(2):153-156.
13. Hardee KA, L.; Rottach, E.; Jolivet, R.; Kiesel, R.: The policy
dimensions of scaling up health initiatives. In. Washington,
DC: Futures Group, Health Policy Project; 2012.
14. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson
L: 'Doing' health policy analysis: methodological and
conceptual reflections and challenges. Health policy and
planning 2008, 23(5):308-317.
15. Buse K, Mays N, Walt G: Making Health Policy, vol. First
edition. London: Open University Press, London School of
Hygiene and Tropical Medicine; 2005.
16. Walt G, Gilson L: Reforming the health sector in developing
countries: the central role of policy analysis. Health policy
and planning 1994, 9(4):353-370.
17. Spicer N, Bhattacharya D, Dimka R, Fanta F, Mangham-
Jefferies L, Schellenberg J, Tamire-Woldemariam A, Walt G,
Wickremasinghe D: 'Scaling-up is a craft not a science':
Catalysing scale-up of health innovations in Ethiopia, India
and Nigeria. Soc Sci Med 2014, 121C:30-38.
82
18. Ir P, Bigdeli M, Meessen B, Van Damme W: Translating
knowledge into policy and action to promote health equity:
The Health Equity Fund policy process in Cambodia 2000-
2008. Health Policy 2010, 96(3):200-209.
19. Brugha R, Varvasovszky Z: Stakeholder analysis: a review.
Health policy and planning 2000, 15(3):239-246.
20. Varvasovszky Z, Brugha R: A stakeholder analysis. Health
policy and planning 2000, 15(3):338-345.
21. Gilson L, Raphaely N: The terrain of health policy analysis in
low and middle income countries: a review of published
literature 1994-2007. Health policy and planning 2008,
23(5):294-307.
22. Everybody's business: strengthening health systems to
improve health outcomes. WHO's framework for action
Geneva: World Health Organization; 2007.
23 . Basinga, P.,Gertler, P., Binagwaho, A., Soucat, ALB, Sturdy, J.
and Vermeersch, CMJ. Effect of maternal and child health
services in Rwanda of Payment to Primary Health-Care
providers for Performance: An impact Evaluation. The Lancet
2011, 377: 1421-28.
24. Bhatia and Rifkins. Primary Health Care. Now or Forever? A
case study of a Paradigm change? International Journal of
Health Servies 2013, 43(3): 459-471.
25. Bonfrer, I., Soeters, R., Poel, Ellen Van de, Basanya, O., Longin,
G, Looif, F.vande and Doorslaer, EV. Introduction of
Performance-Based Financing In Burundi was Associated
With Improvements in Care and Quality. Health Affairs 2013,
33(12): 2179-2187.
26. Bonfrer, I., Poel, Ellen Van de, Doorslaer, Eddy Van. The effects
of performance incentives on the Utilization and Quality
83
maternal and child care in Burundi. Social Science and
Medicine 2014,123: 96-104.
27. Lagarde, M., Wright, M., Nossiter, J. and Mays, N. Challenges of
payment –for –performance in health, care and other public
services –design, implementation and evaluation. Policy
Innovation Research Unit 2013. London School of Hygiene
and Tropical Medicine.
28. Savedoff, W.D. Incentive Proliferation? Making Sense of a New
wave of Development Programs. An Essay: Centre for Global
Development.www.cgdev.org/content/publications/detail/1
425405. 2011.
29. Witter, S., Toonen, J., Meessen, B., Kagubare, J., Fritsche, G.
and Vaughan, K. Performance-based financing as a health
system reform: mapping the key dimensions for monitoring
and evaluation. BMC Health Services Research 2013, 13:367-
377.
30. Bellows, B., Odoyo, E, and Obare, F. Evaluation of
Performance-Based Finance (PBF) under the Health Sector
Services Fund (HSSF) in Samburu County, Kenya. Nairobi :
Population Council and Ministry of Public Health and
Sanitation. 2012.
31. Government of Kenya/Ministry of Health. Results Based
Financing (RBF) Operational Manual. Nairobi : Ministry of
Health. 2013.
32. Opwora, A., Kabare, M., Molyneux, S. and Catherine Goodman
The implementation and Effects of Direct Facility Funding in
Kenya’s Health Centres and Dispensaries. The Consortium for
Research on Equitable Health Systems (CREHS). Nairobi :
KEMRI/Welcome Trust. 2009.
33. Government of Kenya. The New Constitution,2010. Nairobi :
Government Press.
84
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8.0 Annexes1. Summary of Interviews conducted
S.No Organization Level of Responsibility Date of Interview
1 Pop Council NGO manager 05/03/15
2 MoH Policy Maker 06/03/15
3 MoH Field Manager 23/03/15
4 MoH Policy Maker 26/03/15
5 AMREF NGO manager 17/03/15
6 World Bank Donor Rep 27/03/15
7 DANIDA Donor Rep 30/04/15
8 County Government Health Manager 06/05/15
9 County Government Health Manager 08/05/15
10 County Government Health Manager 07/05/15
11 County Government Health Manager 07/05/15
12 County Government Health Manager 07/05/15
13 County Government County Policy Maker 20/05/15
14 County Government Health Manager 20/05/15
15 County Government Health Manager 19/05/15
16 County Government Health Manager 21/05/15
17 UNICEF/USAID NGO manager 21/05/15
18 County Government Health facility Manager 21/05/15
19 County Government Health Field Manager 27/05/2015
20 County Government Health Manager 27/05/2015
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21 County Government Health Policy Maker 27/05/2015
22 County Goverment Health Manager 27/05/2015
2. INSTRUMENTS OF DATA COLLECTION
Members of the PBF TWG/Development partners
The TWG has played an important and long-standing role in promoting
PBF in Kenya, a role that has likely served as a model among countries
promoting integration. The TWG was important in coalescing the support
of MoH and program partners around a common vision, resulting in
standardized policies and guidelines.
1. In view of the past accomplishments of the TWG, what will be the
role of the TWG moving forward?
2. To what extent did the TWG participate in developing the revised
PBF implementation manual?
3. Are you aware of what financial considerations may have been taken
into account in the scale up of the Samburu PBF project? Were any
of the cost analyses conducted in or the cost-efficiency of providing
services, cited in budget negotiations?
4. How has the scale up of the PBF in Kenya integrated the
management of the funds into the national system? (Probe to
document any challenges in the integration)
5. In your opinion, are the existing policies and guidelines sufficient to
support PBF scale up? What additional tools might be needed to
facilitate the full practice of PBF scale up?
6. What progress has been made in the institutionalization of PBF in
the counties selected for the scale up?
7. What approaches have been used to support PBF scale up? How
successful have these been? What will it take to ensure PBF scale up
become a fully functioning component of health care throughout the
country?
8. What opportunities and challenges does devolution present? How
can the challenges be addressed? (Probe to know what new
87
institutions or systems have been put in place in healthcare due to
devolution process.)
9. What are your concerns, if any, with the devolution of authority to
more local control, and how is that likely to affect the further
development of PBF scale up? (Probe to know if the design has
included the political considerations of the devolved units)
10. What are the key lessons learnt working with different
institutions (public sector partners, local NGOs, political institutions
and government departments at the national and county levels)
regarding the scale up and sustainability of PBF?
11. What are the best practices and lessons learnt in the PBF scale
up? These might refer to:
a. Developing institutional capacity to implement scale up of PBF
b. Building the capacity to oversee coordination at National and
County levels
c. Resource allocation
d. Public-private partnerships
12. What changes do you recommend for PBF programs in the
future to make them more effective in delivering sustainable
services that reach targeted populations?
Ministry of Health-National government
Key in-depth Guide
1. How does your MOH department work with PBF project? How have the lessons learn from the Samburu pilot contributed to
the work of the various departments in regards to PBF project?
2. How has MOH contributed to building PBF implementation capacity in
the various MOH departments? What successes and challenges have been experienced in working
with the various MOH departments including the following: NHIF
Department of Family Health) Orphans and Vulnerable Children (OVC) Secretariat
Directorate of planning and Health financing
88
3. What approaches have been used to support scale up of PBF in Kenya? How successful has this initiative been?
3. What progress has the project made in building institutions to provide leadership and coordinate PBF activities at the national and county
levels? 4. What processes were put in place to operationalize the National and
County PBF Committees to drive the scale up approaches? Please explain the process and any challenges encountered)
5. What have the achievements been in terms of strengthening leadership, management and governance of PBF implementation in
Kenya? (i) At national level (ii) County level. To what degree is this sustainable?
6. What opportunities and challenges does the devolution present? How could the challenges be addressed? (Probe to know which new
institutions have been put in place in healthcare due to devolution process)
7. What role do the newly created political institutions play in the PBF
scaling up in Kenya? (Probe to establish whether the role of county
assemblies in devolved funds management has been incorporated in
the PBF scale up)
8. What are the key lessons learnt working with different institutions
(private sector partners, local NGOs, and government departments at the national and county levels) regarding the implementation and
sustainability of PBF? 9. How do the decision rights or powers transferred to the devolved
system likely to affect the scaling up of PBF in Kenya? (Probe for potential for conflicts between different institutions in relation to PBF
scaling up) 10. What have been the bottlenecks, best practices and lessons learnt in
the scale up of PBF? Please list all the lessons learnt, including those learnt in:
Developing institutional capacity to implement PBF
Building the capacity to oversee coordination at National and County
levels? public-private partnerships
Involving the participation of Health Facility Committee members
11. What change so you recommend for PBF programs in the future to make them more effective in delivering sustainable
services that reach targeted populations?
89
Ministry of Health-County government
Key in-depth Guide
12. How does the county government work with PBF project?
How have the lessons learn from the Samburu pilot contributed to
the work of the various departments within the governments in
regards to PBF project?
13. How has MOH contributed to building PBF implementation capacity
in the various MOH departments? How is the relationship of the
national and county government in relation to PBF implementation?
What successes and challenges have been experienced in working
with the various county departments under which the program falls?
14. What approaches have been used to support scale up of PBF within
the county? How successful has this initiative been? Please explain the
process of getting to the current implementation stage? (Probe
facilitators and challenges)
15. What progress has the project made in building institutions to
provide leadership and coordinate PBF activities at the county levels?
Please explain
16. What processes have been put in place to operationalize the County
PBF Committees to drive the scale up approaches? Please explain
17. What have the achievements been in terms of strengthening
leadership, management and governance of PBF implementation in
Kenya? (i) At national level (ii) County level. To what degree is this
sustainable?
18. What opportunities and challenges does the devolution present?
How could the challenges be addressed? (Probe to know which new
institutions have been put in place in healthcare due to devolution
process and how they would affect the PBF scale up)
19. What are the key lessons learnt working with different institutions
(private sector partners, local NGOs, and government departments at
the and county levels) regarding the implementation and sustainability
of PBF?
20. How have the health facility committee members been incorporated
in the scaling up of Perfomance-Based Financing (PBF) in Kenya?
(Probe to know how the design takes into consideration efforts to
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create awareness among some sections of the vulnerable and poor
groups in the community)
21. What role do the newly created political institutions play in the PBF
scaling up in Kenya? (Probe to establish whether the role of county
assemblies in devolved funds management has been incorporated in
the PBF scale up)
22. How are the decision rights or powers transferred to the devolved
system affecting the scaling up of PBF in Kenya? (Probe for potential
for conflicts between different institutions in the county in relation to
PBF scaling up including the newly created political institutions and
their authority)
23. What have been the bottlenecks, best practices and lessons learnt in
the scale up of PBF? Please list all the lessons learnt, including those
learnt in:
Developing institutional capacity to implement PBF
Building the capacity to oversee coordination at National and County
levels?
public-private partnerships
Involving the participation of Health Facility Committee members.
24. What change do you recommend for PBF programs in the future to
make them more effective in delivering sustainable services that reach
targeted populations?
91
25.