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Bringing cash to the frontline: the experience of the Health Sector Services Fund in Kenya

8/21/2012

19 Commentaires

 
The Ministry of Public Health and Sanitation of Kenya is developing a pilot Performance-Based Financing (PBF) project in Samburu Central district. Bruno Meessen met Dr. Rael Mutai, the lead person for the project, at a workshop organized by the World Bank in Livingstone, Zambia (May 29-June 1). 
 
BM: In this workshop you presented the Kenyan PBF pilot project. You mentioned a so-called Health Sector Services Fund. Can you tell us a bit more about this fund?

RM: Sometime in 2003, the Ministry of Health did a study to see what proportion of public funds allocated to primary level facilities actually made it to the facilities. It was found that hardly 30% of the funds that left the central government ever reached the small facilities. So the government came up with the idea to do a pilot of a direct funding of these facilities. The pilot was commissioned in the Coastal Province of Kenya. Over a period of 3-4 years, they were able to see these funds that had been channeled directly to facility account were having an impact. Based on that study, the government came together and decided to form the Health Sector Services Fund (HSSF). The HSSF is supposed to be rolled out to the rest of the country.

The strategy states that primary health facilities have to an open bank account and for the governance of the funding, to set up a health facility management committee. The head of the facility is the secretary of this committee; normally a person from the community acts as the chairman. Once that this is established, the whole facility committee is gazetted, so it is a legal entity. Then they are able to decide on their fund.

Are all health facilities eligible for the fund? Do all the health centers get the same amount or is it a formula taking into account, for instance, the population in the catchment area? Practically, how does it go?

The government has determined what to give on a quarterly basis per level of services  - dispensaries (serving population of up to 10,000) and health centers (serving population of up to 30,000) only. In this phase one of the project, the fund works with government facilities only. But in one year or two, once accountability rules are clarified, money will be given even to the faith-based facilities. Yes, there is a criterion that we used to determine which different sections of the country receive different amount. But there is more or less a baseline for a basic amount that all health centers (Ksh. 112,500 per quarter) must receive, there is a basic amount for the dispensaries (Ksh.27,500 per quarter) (1); It is only now that we are factoring in other equity parameters such as the accessibility or the poverty index.

The transfer to the health facility is organized in three components. The 1st component, which is the bulk of the transfer, is for operations and maintenance at the facility level; it covers basic recurrent costs including payment of casual laborers. The 2nd component is for the health facility to implement its Annual Operations Plan, which is broken into quarterly implementation plans listing activities the health facility will do (outreaches, a specific service in the area of maternal and child health, voluntary male circumcision…); health facilities define themselves what to do. The 3rd component is an incentive component, the PBF related part.

Can you indeed explain the link between the HSSF and PBF?

During the design of HSSF, it was envisaged that a proportion of funds would specifically be paid to incentivize the health facility. These incentives are to be given to the facility, but 40% is for investment and 60% is for the staff. This is just a general guideline, there is autonomy: the health facilities can decide that they even invest all so that they can attract more clients. But as it is in the pilot stage, we said 60% is for the staff, 40% is to be reinvested in the facility.

The way we decided our PBF, it is basically operationalizing the 3rd component of the HSSF. So we designed in such a way that the Health Sector Service Fund Secretariat remains the fund holder. They are the people who have been channeling the funds directly to the health facilities; in this new arrangement they will continue: they will be disbursing the performance incentives to the facilities, through their account. We do not even need to start saying which account is where: the Secretariat has the details, there is a master facility list; we will be able to able to track everything. For accessing the HSS fund, the facilities have already to submit a quarterly implementation plan. In PBF, we tell them it must be a business plan. So, what we do is just to modify the existing system.  Under the routine government system, certain things could not be entered in. For instance, if they are going to incentivize a traditional birth-attendant for them to bring a mother to the facility, in the business plan they can write it comfortably and there is no problem and the money will just be disbursed.

This system looks quite interesting. What is the benefit of bringing PBF to the HSSF?

 The general feeling of the country was that we have invested so much money into the health sector in terms of personnel, in terms of infrastructure, but we are not still meeting our target. It is in the process of trying to accelerate progress towards the Millennium Development Goals, the 4 and 5 specifically. The key asset of PBF is the human resource component.  You can post a staff member in a remote area, within no time he has left the place (very high turnover). We hope that by incentivizing them they might find some motivation to continue giving the services and to improve the quality.

 
(1)     1 Kenyan shilling = 0.0119 US dollars. This means that a dispensary gets around USD 0.13 per year per inhabitant.

19 Commentaires
Frank Verbeke
8/22/2012 02:38:11 am

I very much like the important autonomy the health centers got in deciding what quantitative/qualitative indicators they put in the third (PBF) component. But it also leaves me with a number of questions:
- How to marry this autonomy with MDG 4 & 5 focus of the government? Does this mean that the health centers still operate within some kind of an indicator framework? Do indicators have to be approved by someone before being accepted?
- It looks like there is no formal results verification process in place. Is that right? Do you count on the committee chairman to represent the community as a verification component?

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Dr. Rael Mutai
8/22/2012 05:45:55 am

Thanks for the feedback, actually the indicators for PBF were selected by the TWG on PBF at the Ministry of health with the participation of the DHMT in the pilot site. Primary level facilities provide a comprehensive package of services and report routinely through the DHIS. There is a clearly defined process of data validation inbuilt into the project and its done quarterly. For community verification, the community based organizations and the Community health workers participate.

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DR KIBIAS SIMON K.
8/22/2012 03:17:37 am

Health centres and dispensaries continue to play a major role in delivery of comprehensive primary health services and the health sector in Kenya is thinking in the direction of having comprehensive primary health centres at the community level.Through new health bill and policy there are intentions to merger or upgrade dispensaries into health centres to serve this purpose. MDG 4 and 5 shall receive boost from this line of action which is already underway by construction of 201 model health centres in every constituency in the country.This project is becoming popular by the day in that it had full commmunity participation in selecting the right site and in the management of the project. The project prioritized maternal and child health services with the construction of a modern maternity child clinics and admission rooms. A baseline study on maternal and child health indicators has been established for these health in order to inform the future expansion of model health centres establishments. Most forms of financing of services would service the model health easily.

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Joanne Harnmeijer
8/22/2012 04:36:11 am

Nice, such an incremental design. I believe in Zimbabwe there is a similar process in the making, of transforming a pre-existing Health Services Fund (HSF). However in Zimbabwe the idea is to build in the best practices & lessons of the World Bank funded RBF (PBF) which is being implemented in 18 of the country's 62 districts.

I wonder, as more and more countries adopt PBF, if it would be useful for overall M&E to select a limited number of routinely measured "sentinel indicators". Like in an interrupted time series (ITS) design. But intentionally for a limited number of key indicators, across multiple countries. The design should honour the fact that PBF may be embedded in other pre-existing interventions - such as HSF.

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Mwanza Joachim Odonge
8/22/2012 08:21:08 am

Besides what Dr Mutai and Dr Kibias has put out above, there is significant attention to the sites with the model health facilities which includes improved staffing- employment of 35 Nurses , 5 Public health officers to step up the access to skilled providers of the very important Maternal and child health services in the constituencies.
Equipment have also been provided in the mentioned model facilities all over the country.We hope we are on track for the quality health services for all Kenyan as is in our new constitution.


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Dr SEMLALI
8/23/2012 05:34:02 am

Merci de ce partage
Mais, je suis resté sur ma faim concernant l'atteinte des OMD 5 et 6, car ces deux objectifs ne dépendent pas uniquement des établissements de soins primaires, les hôpitaux sont une étape incontournable pour la prise en charge des complications. De ce fait, qu'elle est la part des hôpitaux dans cette équation, et comment on procède pour les cas à référer, (transport, frais d'hospitalisation, médicament...), il y a aussi le problème de la pathologie lourde et maladie chronique...etc.

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Jack Onyando link
8/27/2012 02:33:51 am

HSSF is a great idea. What needs to be done is to also sensitize the community on the availability of these funds so that they can demand for accountability from those managing the funds. Our experience is that awareness levels on the availability of this fund is very low, and NGOs are still called upon to facilitate government operations even where this fund is available.

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rael mutai
8/27/2012 02:51:48 am

Thanks for the feedback. Currently we are working on a Social accountability framework that will enhance accountability and transparency in the utilization of the HSSF funds. But again, the amounts are still very small and facilities/DHMTs will still require additional funds to carry out some of the activities in the workplans.

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Joanne
8/27/2012 07:45:50 am

By the way: great title this - "Bringing cash to the frontline". More catching and true to the spirit than PBF/RBF? PBF/RBF as a means to bring cash to the frontline, or even move the frontline, in ways that can be accounted for. But not a purpose in itself.

Cornelia Wakhanu
8/27/2012 08:58:31 am

HSSF has positive effect. Unfortunately, the HFMC being in charge of this fund need to be empowered with financial mangement and accountability.

This fund is for the health facility and not the HFMC. This fund needs to be made clear. The community under each health facility needs to be aware what is available, the gaps and what needs to be spent and how much.

I also do agree that on the ground, what is expected to be achieved by each DHMT for the entire district is just too big that the few resources available can not even meet a quarter of many targets set. It is the gaps filled through support from NGOS that they are able to meet what is being seen as met.

Despite being suported by NGOs on the ground, many challenges on gaps still remain. It makes me wonder "what about those areas without NGOs Support?". If NGOS were not on the group, what would have been the targets/achievement.

My opinion is that The HSSF financing need to do the following:
1. together with the Community, identify gaps and priority list for attention at the health facility and community level.
2. Use the HSSF fund to fill the gaps identified like- MNCH-maternity unit, equipment, etc.
3. When everything is in the best standard, equip the health facilities with staff and assess and equip them with knowledge and the staffs skills to be handle the activities/procedures gradually through on job training and/ or workshops.
4. Then let the frontline health workers starting from coommunity level upward get rewarded through Performance based health financing.

Note:
1. How do we expect a staff to conduct outreach services when he/she was only provided with a mortobike without fuel and maintenance costs which has been the case? When it breaks down, it is useless. When there is no fuel, it stays unsed.
2. We do not expect much from the health facility staff on the maternal site especially health facility deliveries when the staff has no maternity unit with drainage system and some no delivery coach separate from the examination coach.
3. we do not expect much from the health facility when the staff maning the health facility and always around is a community helath worker not skilled.
4. We do not expect to get much when we are unable to make the lives of the staff who has committed himself or herself to work in that remote area under difficult conditions. the staff feelsmore motivated first by having all necessary basic resources to facilitate provision of service. Then the reward system according to performance sets in automatically.
5. We do not expect to get mothers being attended to during deliveries especiaily at facility level when those who have been performing the activity have been left out. I AM happy that the issue of TBAS is being addressed on change of roles and motivation on reward system. we also do not expect the reward to continue forever as where will the resources continue to come from? As we target the TBAS in change of roles, we must continue direct targeting of women, men, adolescents and youths -every one at the community level through community helath workers to know their right to better services. in doing so, when the funds will not be available, they would have gotten used to the better services and will obviously continue through their continued responsivenes through self demand and utilization.
6. The TBAS need to be assited to start IGAs as a phasing out strategy from direct funding from the reward system. In doing so, they will be committed in their generating their own earning for their living and would not even wish to stay at the perieum of a woman in labour for more hours to days just to get a small token. They will always prefer to tell women in labour to seek health facility services.

If the health facility is well equiped;equipment, supplies and skilled staffing then the reward system can start and be handed over to the individual cadres/ helth facility and communities.

What else do we expect from the above: MDGs 4 & 5 achieved togeher with the remaining six MDGs through an integrated approach which some might not even be able to realize to be addressing (for those not aware of integrated approaches)

I hope this my contribution will be part of the strategy as am one of those in an organization working in partnership with the GOK/MOH and other national NGOs addresing the same MDGs in one of the remote poor and more so "marginallized communities' in kenya. where evryone is fighting and commitment to meeting the AOP despite ups and downs.




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Bruno Meessen
8/28/2012 12:12:57 am

Dear Rael,

Jack and Cornelia mentioned the role of NGOs. Have they anything to do in the HSS Fund? Can you give us a bit more background information about their contribution to the funding of first line public health facilities? Thanks

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Jack Onyando link
8/28/2012 06:26:01 am

Hi Bruno,
I know your question was directed to Rael, but it doesnt harm getting a reply from anyone else.
As it is currently, HSSF is purely a government initiative, of course with support from other development actors like the World Bank. So NGOs currenlty do not contibute directly to the fund.
That said, at the district level, there is the Annual Operational Planning (AOP) process where all actors within the district are brought together and a consolidated district health plan is developed. So the NGOs come in to support part of the plan ,given that the government funding is limited.

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rael mutai
9/8/2012 02:38:53 pm

The HSSF is pool money contributed by WB and Danida. NGOs do not directly contribute to the fund but work with DHMTs and health facilities to address the funding gaps in implementation of annual work plans.

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Timothy Okech
11/25/2013 09:29:39 am

Interesting discusion. My only concern regards two issues namely; i) how will HSSF operate in the country given the devolution of the health system; ii) Given that the fund is largely funded by WB and DANIDA what is being done to enure sustainability; and iii) has the Ministry enhanced the capacity of the committee charged with responsibility of the management of the fund

Charles Muruka
8/29/2012 04:25:14 am

Hello RM:
I wish to further comment on the issue of accountability for the HSSF by the recipients (dispensaries and health facilities): this is a critical area that demands attention, for example, when ‘my facility’ receives these funds and I don't declare it to partners working on the ground and the beneficiary community, then definitely it raises suspicion. However small the HSSF amount is, I recommend that it should be declared to partners. Partners will then have a more realistic picture of what gaps exist. As it is now, generally, requests for support do go to partners with non-disclosure of any available funds.
I have seen some TV adverts on the HSSF, I guess meant to sensitize Kenyans on the existence of the HSSF fund. But how many Kenyans have access to TV? How many Kenyans understand the language of the advertisement (English)? Of course this does not discredit the TV advert, but it should be supplemented by face-to-face awareness creation in the community.
Having a chairman of the facility management committee coming from the local community does not automatically imply that the beneficiary community is aware, since oftentimes they sit in these committees as individuals and never provide feedback to the general population. I recommend that it would not cost much for the health facility in-charge (plus the whole committee) and even the DHMT to use the community strategy platform to sensitize the beneficiary/catchment community about the existence and utilization of the HSSF in the facility. Communities will then be able to evaluate whether the quality and quantity of services are improving or not as a result of the fund, query variations and receive feedback. In an era in which accountability is not only seen as a good practice but also demanded, this recommendation will provide a good forum for beneficiary accountability, complaints handling and response mechanism.
Thank you.

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Muendi Musuva
9/7/2012 09:13:29 am

Indeed HSSF is a novel idea. It was anticipated that the direct facility funding would increase the incomes of health facilities and increase their adherence to the 10/20 policy (where dispensaries and health centers charge patients 10 or 20 Kenya shillings respectively for all services) and hence reducing out of pocket payments. However an evaluation of the HSSF pilot in Coast province by the Wellcome Trust showed that facilities were not complying with the 10/20 policy. In order to pass on the benefits of HSSF to the end users, (the patients) I suggest that continued funding to the health facilities should be contingent on them adhering to the 10/20 policy, and indeed to other minimum standards of care. In future, the HSSF can become a full PBF scheme, where facilities are funded based on their output.

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Cornelia wakhanu
9/7/2012 10:28:15 am

Dear all,

Thanks all for your views.
I go for the view for Muendi Musuva. reason below:

Let us be transparent on this. Especially those affected need to air out their feelings.

Some of the HFMC when approached by some of the DHMTs and raise concerns on spending, some have been resistant. I remember one time a DHMT bitterly lamenting from the way one of the HFMC member responded to a query. The HFMC member said: You are complaining about our financial management just because you were snatched the responsibility and we manage ourselves. You have no access to it as before.

I just wonder how a member can do this and can not be changed. After all the DHMTs are the ones making sure that the activities are ongoing. The HFMC is completely unable even to manage their own staff. You will find a skilled staff not always available and leaving the CHW to provide the services. The HFMC do not matter in this case whether the quality of care if up to-date, but so long as the clients/patients receive the care.

You will find that instead of the HFMC demanding for services for the community as their voice, they a silent. You will find the community members voicing for themselves. You will also find that marginalization just as it is at any level, it might be existing at certain communities and the HFMC can not handle but encourage it. services.

can the HFMC also be able to manage the staff well and even motivate them from the funds to better score more on Performance reward?

LET THE FACILITY BE ASSESSED, BE EQUIPPED WITH BASIC NEEDS/RESOURCES TO PROVIDE SERVICES. LET THEM BE EMPOWERED MORE AND THEN BE REWARDED ON PERFORMANCE. REMEMBER- RESHUFFLING THE HFMC IN CASE OF CONTINUED POOR PERFORMANCE




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ivy muya
2/11/2013 06:04:10 am

This could not have come at a better time for Kenya. Big Q, are there any monitoring and evaluation preliminary findings that have been done yet to see if the poor are still incurring OOP expenditures?

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Sammy Karanja / District Public Health Officer Bungoma West.
7/19/2013 09:58:47 pm

The funds are spent by one person and the entire DHMT is never informed.Can you follow up and see how these funds are spent in Bungoma West District? Also let all DHMT members to be involved and authorize spending of the same through minutes.There is no transparency over HSSF spending in Bungoma West,

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