Assessing the implementation and effects of direct facility funding in health centres & dispensaries in Coast Province, Kenya

Presenter: Catherine Goodman, London School of Hygiene & Tropical Medicine & Kenya Medical Research Institute

Abstract

Background
There is increasing debate over the appropriate way to finance health facilities in developing countries in order to increase quality and utilization. While several countries are experimenting with “pay for performance” mechanisms, they have been criticized for their administrative burden and potential for perverse incentives. In Kenya an alternative approach has been piloted, termed direct facility funding (DFF), which links funding levels to general indicators of facility size and workload rather than specific output targets. The funds are transferred directly into the facility’s bank account, and a workplan and budget are prepared by the Health facility committee (HFC). With the HFC made up of community members and the facility in-charge, DFF has the additional potential advantage of strengthening community involvement in health delivery.

Methods
We evaluated the implementation of DFF in health centres and dispensaries in 2007-8 in two districts in Coast Province, purposively selected to include one stronger and one weaker performer based on managerial views. Quantitative data collection at 30 randomly selected public health centres and dispensaries included a structured interview with the in-charge, record reviews, and exit interviews with 10 patients per facility. In addition, in-depth interviews were conducted with the in-charge, and other members of the HFC at 12 purposively selected health facilities, as well as with district staff and other stakeholders. As baseline data were not available we focused quantitative measures on process outcomes, and used qualitative methods to explore perceived impact on utilization, quality of care, and the financial burden on households.

Results
In general DFF procedures were well established: HFCs met regularly, workplans were produced, money was accessed, and accounting procedures were broadly followed. DFF made an important contribution to facility income, accounting for 47% in health centres and 62% in dispensaries. The main items of DFF expenditure were wages (32%), travel (21%), and construction and maintenance (18%). DFF was perceived to have a highly positive impact through funding support staff such as watchmen, cleaners and patient attendants; outreach activities for immunisation and antenatal care; building renovations; patient referrals; and increasing the activity of HFCs. This was perceived to have improved health worker motivation, utilisation and quality of care.

A number of problems were identified. HFC training was reported to be inadequate, and no DFF documentation was available at facility level, leading to confusion on key aspects of the scheme. Despite the increased funds, overcharging of user fees remained common, and understanding of DFF among the broader community was very limited. Finally, relationships between HFCs and health workers were sometimes characterized by mistrust and resentment.

Discussion
DFF was seen as highly valuable and in general the scheme was implemented well, indicating that even without performance targets, an increase in funding at peripheral levels can have an important impact. The Kenyan Government plans to scale up DFF nationwide. Our findings indicate that this is warranted, but that it should include improved training and documentation; greater emphasis on community engagement; and insistence on user fee adherence as a prerequisite for receipt of funds.