By Boniface Mbuthia, Janet Keru, Geredine Kandie, Felix Murira, and Anne Musuva

The availability of essential medicines and supplies is critical for accelerating progress towards universal health coverage (UHC). Since Kenya embraced devolution in 2013, its 47 newly formed county governments have become responsible for allocating financial resources for health supplies on behalf of public sector health facilities in their jurisdictions. Exactly how they go about this and its implications for the availability of commodities—which include essential medicines, reagents and non-pharmaceutical supplies—has not been well documented.

To fill this gap, ThinkWell collaborated with inSupplyHealth and the Chartered Institute of Procurement & Supply (CIPS) to holistically map processes for forecasting and financing existing bottlenecks, procurement of commodities, and the implications for the availability of health supplies. The team undertook a rapid landscaping analysis in four focus counties during the last quarter of 2022 and spent the first quarter of 2023 validating findings with each county government.

On March 28^th, ThinkWell, inSupplyHealth, and CIPS organized a meeting in Nairobi, Kenya where officials from the Ministry of Health (MOH), Council of Governors, delegations from the four counties, development partners, and other stakeholders met to discuss emerging insights from the county deep-dives. The MOH delegation included officials from the country’s Division of Health Products and Technologies. Isiolo, Nakuru, Trans-Nzoia, and Kakamega Counties all sent teams to join the meeting. Supply chain partners such as Africa Resource Centre (ARC), Kaizen joined the discussion. The dialogue focused on three key themes:

1. Insufficient allocation for health supplies: Counties are not allocating sufficient resources for health supplies. In collaboration with partners, MOH developed a systematic, step-by-step approach to forecasting and quantifying health commodity requirements and costs; however, counties are not following these guidelines. Consequently, their allocations are lower than the need.
2. Low execution of the budget for health supplies: Less than 50% of the budget allocated for health supplies is being spent. This is attributed to several factors including pending bills from previous financial years, delays in the government transfers, and delays in the approval process for local purchase orders.
3. Health facilities with financial autonomy are better positioned to fill gaps: A best practice was observed in Nakuru County where the public hospitals were able to use their own-source revenue to source funds for health supplies. The county government has established health facilities as procurement entities so that they can engage suppliers directly and account for their expenditure using processes that follow public procurement and public financial management regulations of the country. Hospitals in the county were noted to have better availability of health supplies as a result compared to hospitals in counties that did not allow autonomy.

The team is now working on a detailed technical brief documenting the findings from the landscaping analysis on these three topics. We expect to publish it later this year. So, stay tuned!

Header image: From left to right, Dr. Claver Kimathi (Isiolo County), Dr. Eunice Gathitu (MOH), Dr. Emmanuel Wamalwa (Council of Governors), Dr. James Riungu (Chemonics), Mr. Josephat Ngesa (CIPS), and Dr. Anne Musuva (ThinkWell)

The 15th IHEA World Congress on Health Economics will be held July 9-12, 2023, in Cape Town, South Africa, and our teams are prepping for our biggest attendance yet. Our projects will be featured in five pre-congress sessions all listed below, all of which are available for FREE virtual attendance.

The IHEA Congress is an international convention for health systems experts to discuss the latest data, methodologies, findings, and tools in the pursuit of improving health care around the globe. This year’s theme is “Diversity in Health Economics.” The event will take place in both buildings of the Cape Town International Convention Centre (CTICC). Find more information on ThinkWell’s IHEA pre-congress sessions, how to register, and the agenda below.

As more details around schedules become available, this page will be updated. See you in Cape Town!

Attend Pre-Congresses Virtually

Pre-Congress Registration

Pre-Congress Agenda

Pre-congress sessions will run July 8-9, 2023. ThinkWell will participate in five sessions detailed below.

Saturday, July 8

9 AM-12:30 PM

Organizers: ThinkWell, Center for Global Development, and KEMRI Wellcome Trust Research Programme

There is growing consensus that channeling funds to health facilities and granting them more autonomy will improve the delivery of primary health care services. In this session, we will explore the evidence about the impact of direct financing for facilities on access to health products, especially essential medicines.

People-Centred, Efficient Health Care Services: Rethinking Sustainable Health Care Financing in the Context of the African Union’s ALM Declaration on Domestic Financing for Health

1:30 PM-5 PM

Organizers: ThinkWell, The Global Fund, AUDA-NEPAD, Eastern African Community, ODI, and SADC

In uncertain times, the need to ensure that adequate, effective, and efficient financing for healthcare in Africa remains a political priority has never been clearer.  This is the goal at the heart of the African Unions ALM initiative on domestic financing for health. We hear from the organizations tasked with implementing that ambitious agenda, together with member states implementing their own health financing reform agendas.

9 AM-5 PM

The Immunization Economics Special Interest Group welcomes researchers to join a two-day meeting to take stock of the latest evidence and research projects, exchange research approaches and methods, and to discuss research priorities. Topics on the agenda will include costing, value of vaccines, immunization financing, and the use of economic evidence for policy and programming.

Register for this session here

Sunday, July 9

8:30 AM-12 PM

Organizers: ThinkWell, R4D, and WHO

This bilingual session (English-French) brings together diverse country experiences to discuss the latest research on contributory social health insurance and non-contributory/free healthcare schemes. The session facilitates an exchange between African, Asian, and Latin American speakers, explores the politics behind these reforms and how these schemes can be improved to achieve UHC.

1 PM-4:30 PM

The SDGs push all countries to achieve UHC by 2030; however, UHC will not be achieved unless sustainable health financing is in place. Many countries have inadequate comprehensive analyses of sustainable health financing. This session explores several health financing models and the respective performance of current UHC in four LMICs: Indonesia, the Philippines, India, and Sri Lanka.

8:30 AM-4:30 PM

The main IHEA congress will be held July 10-12, 2023. The detailed agenda for each presentation can be found HERE. Please visit this page to access titles, times, and descriptions for each presentation.

IHEA Congress Information

Congress Registration

Attend Pre-Congresses Virtually

On June 1, 2023, at 9:00 AM-EST, ThinkWell hosted the third installment of the Counterpoint webinar series titled “Financing health facilities directly: What is all the fuss about?”

During this webinar, we explored the topic of financing health facilities directly.

Watch the recording

There is a growing consensus that granting health facilities in the public sector more funds and greater autonomy is critical for improving primary health care (PHC) delivery. This was one of the themes highlighted by the Lancet Global Health Commission on financing primary health care, which found that public sector PHC facilities could retain and manage funds in fewer than 40% of low- and middle-income countries (LMICs). The report noted that direct financing for public facilities will allow them to improve service readiness and responsiveness. It is also a necessary precondition for them to feel incentivized by signals from public purchasing entities attempting to advance health system goals like improved access, equity, quality, and efficiency. There has been a spate of papers on the topic recently, including by the World Health Organization (WHO) and the World Bank.

And yet, giving health facilities greater financial autonomy is not a new idea as such. Many types of management entities to produce goods and services have been around for centuries. More critically, the merits of granting hospitals autonomy have been debated extensively as part of the new public management discourse since the 1980s. Not everyone is convinced. Some feel that local governments are better positioned operationally to manage service delivery instead of expecting each facility—including small health centers and dispensaries—to manage their own affairs.

In this webinar, we had a candid conversation with two leading voices on the topic about why the push for getting more funds and management of service delivery to the frontlines and why some continue to challenge the idea. We discussed why this is an important issue for LMICs to explore as they develop and execute strategies to make progress towards universal health coverage. ThinkWell Senior Fellow, Nirmala Ravishankar hosted the webinar featuring two experts:

Nirmala Ravishankar is a Senior Fellow at ThinkWell.

Sheila O’Dougherty is a health financing and management expert who retired from her position as Vice President at Abt Associates in 2020. Sheila led USAID-funded health systems strengthening project implemented by Abt Associates that supported far-reaching government reforms to enable direct financing for public facilities in Central Asia and Tanzania. She is the lead author of joint WHO-World Bank brief on direct financing for health facilities.

Edwine Barasa is the Director of the Nairobi Program of the KEMRI Wellcome Trust Research Program in Kenya. He was instrumental in documenting how health facilities lost financial autonomy when Kenya devolved key decision-making powers from the central government to newly formed county governments and has published extensively on the question of decentralization and facility autonomy.

Some of questions we posed to these experts are as follows:

1. What does it mean to directly finance facilities? Why the focus on financial autonomy?
2. Have countries done this before? What does their experience teach us?
3. Many countries have pursued devolution of decision-making powers to local governments. Is that the same thing? Is that not enough?
4. Are there any risks to giving more money and control to public facilities? How can they be mitigated?
5. Where is this agenda headed? What should health financing analysts be exploring? What should health financing policymakers and practitioners be doing?

Counterpoint is ThinkWell’s signature series of webinars that offers a platform for free and frank debate about questions related to health system strengthening. Through these honest discussions, we strive to both challenge dominant paradigms and scrutinize new trends to ascertain their merit.