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By Anne Musuva, Country Director, ThinkWell Kenya

Much has been written about the inadequate or delayed flow of funds to frontline providers and its contribution to poor service delivery. The Lancet Global Health Commission on financing primary health care notes that because of insufficient public spending in many places, primary health care is not fully meeting the needs of people.

I gained a new, more grounded appreciation for this problem when I recently visited a series of dispensaries and health centers in a western county of Kenya. At many of these health facilities, casual staff like cleaners and clerks had not been paid for months because the funds received from the county were inadequate and often delayed.

Other facilities I found understaffed—some staffed by a single nurse—and it is not rare to find these facilities closed because the managing nurse is on leave or away for training. When the nurse is available, patients are often sent away to buy drugs from private pharmacies because the dispensary is out of essential medicines. These circumstances are common in many other parts of the country and point to significant under-resourcing of primary health care (PHC) in Kenya as well as poor fund flow to frontline providers.

The importance of PHC

In 1978, the International Conference on Primary Health Care signed the Declaration of Alma-Ata and called for strengthening of PHC, particularly in low- and middle-income countries. PHC is a whole-of-society approach to health that puts people and communities at the center of their health, focuses on patient needs, and shifts focus away from hospitals and specialist care. Equitable and high-quality PHC is the foundation of a strong health system and is essential for achieving universal health coverage (UHC).

What Kenya has gotten right

Kenya has made significant progress in expanding equitable access to PHC. Inspired by the Declaration of Alma-Ata, in the 1990s, the nation introduced user fee exemptions in public primary health care facilities to expand access to PHC. In 2006, Kenya launched a community health strategy that outlined services to be offered at the community level.

In 2013, Kenya adopted a devolved system of government which made the delivery of health services a county responsibility. Since then, county governments have expanded geographical access to health care by constructing health facilities, particularly dispensaries and health centers, referred to as PHC facilities. Access to PHC services was further improved through the free maternity program, Linda Mama, launched in 2013. The national government later introduced the “user fee forgone” grant to compensate PHCs for revenue lost from user fee exemptions. These funds were used for facility operations, including filling supply gaps and paying casual workers.

In 2015, the National Health Insurance Fund (NHIF) shifted from a focus on hospitalization to an expanded benefit package that includes outpatient care. The NHIF introduced capitation, a population-based provider payment mechanism that can improve equity and strengthen primary health care. Additionally, DANIDA, Denmark’s Development Corporation provides funds to PHC facilities for their operations and maintenance.

Currently, the Ministry of Health (MOH) is pursuing a number of reforms to strengthen PHC. The government is rolling out primary care networks which seek to improve PHC through reorganizing service delivery around a network of community units and PHC facilities. The MOH has also announced plans to recruit community health promoters across all counties and the establishment of a PHC fund to further improve PHC.

The glass half empty

Despite Kenya’s recognition of PHC as the backbone of UHC and the country’s immense milestones, we continue to face challenges in advancing the PHC vision. These include inadequate financing for PHC and lack of financial autonomy which lead to compromised quality, inadequate human resources, and drug stock-outs. Secondary and tertiary facilities receive the lion’s share of resources, including direct financing, human resources, and drug supplies. ThinkWell conducted preliminary analyses of several counties which show that PHC facilities on average receive less than 20% of a county’s health allocation yet constitute over 90% of the facilities and provide at least 60% of the services in a given county. Financing of the community health strategy and  paying stipends for community health volunteers has been inconsistent.

Several recent developments have jeopardized nationwide PHC financing. In 2021, the national government discontinued the user fee forgone grant for PHC facilities and converted the conditional grant to an equitable share grant for counties. The counties have full discretion over these funds, many of which have not been channeled to PHC facilities. DANIDA, which remained a main source of direct financing for PHC facilities, announced plans to phase out this funding by 2025.

Following the loss of two primary funding sources, PHC facilities are left with limited options, including the NHIF and county grants in the few counties that provide them. A facility’s access to NHIF revenue depends largely on whether its county has enacted legislation allowing facilities to retain and use funds generated from the NHIF, including from Linda Mama and from capitation payments. 21 counties have not allowed facilities to do this. Providers in these counties have little incentive to submit claims to the NHIF, leading to loss of NHIF revenue. As a result, mothers coming to deliver at PHC facilities in these counties are often sent away for drugs and supplies, defeating the purpose of Linda Mama, a program premised on free care to vulnerable women at point of use.

So, what should be done?

As Kenya rolls out its ambitious UHC program, we must strengthen PHC to deliver on the UHC promise. The government will need to prioritize the following:

Review resource allocation to prioritize PHC.

This will involve not only increasing allocation to the health sector, particularly PHC, but also reviewing how resources are allocated between PHC, secondary care, and tertiary health care. These allocations should be commensurate with the health care demands at each level. This is at the heart of strategic purchasing, a health financing function which seeks to allocate resources based on information about population needs and provider behavior.

Enact legislation to grant facilities financial autonomy.

The national government or counties should enact legislation that allows all health facilities, including primary health facilities , the autonomy to raise, retain and use funds at facility level. This will mean that facilities can retain NHIF revenue for the services they provide and would be incentivized to make claims to NHIF.

Instate direct facility financing.

As the main sources of direct facility funding dry up, counties should consider directly funding PHC facilities for their operations to improve service delivery. Facility managers are best placed to determine their priorities and manage their funds to meet the needs of the communities they serve. This should be accompanied by support to ensure adherence to the public financial management rules to ensure funds are well used and facility managers are accountable.

Prioritize service delivery.

Investing in additional facilities should be preceded by careful consideration of the need for a facility and the availability of resources to maintain it. Preliminary analysis suggests that counties should shift their priority from building new facilities to resourcing existing facilities and improving quality of care. The focus should be on ensuring existing facilities are well equipped, are stocked with medicines, and have adequate and well-trained health workers.

Conduct further research.

There is a clear need for further evidence on how best to finance and incentivize PHC to deliver high-quality, cost-effective, and equitable care. We need to track financing levels, sources, and expenditure for PHC, and measure what funding levels, strategies, and incentives are associated with better outcomes.

As Kenya continues to deal with the effects of the Covid-19 pandemic and face a triple burden of disease, financing PHC is even more important and should be a key priority for government, at both the national level and county level. The government’s plans to roll out primary care networks and improve PHC financing are a great opportunity for strengthening primary health care. The implementation of these reforms and their outcomes should be tracked closely to inform policy.

In October 2022, the Strategic Health Purchasing Pilot for Maternal and Newborn Health Services (“the pilot”) launched in Serang District of Indonesia. The pilot is a collaborative effort from the Ministry of Health and Indonesia’s Health Insurance Agency (BPJSK) to improve the way that maternal and newborn health services are paid for under the country’s national health insurance program (JKN). It comes in response to challenges with unpredictable service quality and financial strain on JKN. The innovative design of the pilot seeks to strengthen the benefits package, contracting arrangements, provider payment mechanism, and monitoring of maternal and newborn health services. Ultimately, this will reduce spending inefficiencies and promote better health outcomes for pregnant people and their children.

USAID’s Health Financing Activity (HFA)led by ThinkWell and implemented with Center for Health Economics and Policy Studies at the University of Indonesia, the Center for Health Policy and Management at Gadjah Mada University, and Results for Development (R4D)is providing technical support to the Ministry of Health and BPJSK. HFA’s collaborative and locally led approach has been instrumental to the success this initiative has seen so far. The pilot fosters active engagement and coordination among policymakers, purchasing agencies, and providers to effectively monitor and support maternal and newborn health service deliveryan achievement that has been lauded widely by those participating in this initiative. Portions of the pilot design are also already being adopted at the national level, and the pilot is now being expanded to include more facilities in the implementation region.

The pilot is ongoing and closely evaluated through implementation research. In a blog posted by ThinkWell’s partner, R4D, HFA experts share three main lessons from the process which they believe led to the successful launch the pilot and has set it up for a lasting impact:

  1. Co-creation with local stakeholders has grounded the design in local realities and was fundamental to promoting local ownership of this pilot.
  2. Collaboration and established partnership protocols among national and subnational health agencies built a strong foundation for scale-up.
  3. Placing local voices in the lead improves pilot performance and leaves a lasting impact.