Data collected included qualitative interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. The approach and tools were based on the theory of change, but were kept deliberately open to allow for the identification of unintended and unexpected effects, including on the broader health system. Facility-based empirical work focused on health centres, given their longer experience with HSSF by the time of data collection, while national level interviews and document reviews covered HSSF in both health centres and dispensaries.
Theory of change underpinning HSSF. Source: Opwora et al. Four key informants were interviewed in both and , four only in and one only in Interviews concerned their roles in support, supervision and oversight of facility level funding, and their perceptions of HSSF and its implementation.
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District and facility-based data collection took place in April and May Five districts were purposively selected to ensure a range of socio-economic levels and geographic locations two rural, two urban and one mixed. In each district, one weak and one strong performing health centre were selected on the basis of discussions with DHMT members. Facilities perceived as substantial outliers in performance terms were excluded.
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Most In all 5 districts and 10 health centres, we reviewed records on income and expenditure from January to December In the 10 facilities, we also observed whether information on income, expenditure, user fees, committee members, HSSF and patient rights was publicly displayed. The authors received ethical approval from their institutions. These are just some of the financial management documents and reports that facilities have to fill for HSSF, as outlined in the Operational Guide Table 1 Government of Kenya a.
Documents required for the management of HSSF at facility level and their availability at the 10 health centres visited.
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The DHMT review and monitor facility records and reports, and account for their own funds in similar ways to facilities. The District Treasury was not given a specific role in HSSF, although it does have general fiduciary oversight of all government activities in the district, including health facilities. When reports are approved, money for the next quarter is transferred directly into the facility and DHMT bank accounts from national level, and AIEs are issued for each facility at national level.
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In mid, there were CBAs employed an average of 2 per county. Should further financial management support be needed by facilities, they can use HSSF funds to contract accounts clerks.
Prior to HSSF roll out in ; the HSSF secretariat facilitated a 5 day training course for provincial managers, who in turn organized 4—5 day training workshops in their respective districts for facility in-charges and 2—3 HFMC members per facility. In addition to HSSF modalities, the training covered the use of Electronic Tax Register machines which were introduced in facilities in early to keep track of patient user fee payments.
To support training, two HSSF manuals were produced, and later updated. These figures had been improving over time. In our interviews in districts and health centres, there were generally positive responses regarding having received HSSF funds and structured AIEs. Furthermore, having AIEs that also covered user fees reportedly assisted with transparency, and in reducing conflicts between in-charges and HFMCs about allocation of user fee revenues.
Delays were attributed to facility AIEs having to be signed off quarterly in Nairobi, and facilities having to wait for others in the district before QIPs or monthly reports were forwarded to the national level by DHMTs. Delays in funds and AIEs remained a major concern given the potential to undermine a key HSSF goal—to reduce the complexity and delays in accessing funds for facilities.
Given that user fees were banked and accessed with HSSF funds, these delays were also impacting on access to user fees. Balancing the time requirements for accounting, documentation and patient care was described as extremely difficult:. District and facility managers relied heavily on CBAs to assist with financial accounting and documentation.
CBAs assisted facilities in prioritizing among the many required financial management documents, and improvising to cope with the frequent unavailability of official versions of documents Table 1.
Facilities for example make their own ledgers and forms using photocopies or standard black exercise books. DHMT members reported some lack of clarity between the DHMT and CBAs regarding responsibility for conducting and funding the day to day training and support for in-charges on financial management.
Concerns may have been linked to some lack of support from DHMTs: HSSF led to their losing control over facility funds which had previously been channeled through them; they were being directly allocated relatively small amounts:.
The requests from [DHMT] departments are just overwhelming and the amount is so small. As noted in a Aide Memoire:. Posting of accountants to districts is yet to help improve compliance with the government of Kenya fiduciary procedures under HSSF. Many interviewees felt that these ways of working were contributing to the verticalization and centralization of HSSF.
However, whether or not this was a major concern was a source of debate.
Those against integration also noted that this verticalization and parallel system was a general problem for the Ministries of Health, and not an issue specific to HSSF. These nationally representative findings were reflected in the 10 health centres we visited. All had active committees, most of which were re-constituted within the last 3 years, in accordance with the guidelines. In addition to meeting at least every quarter, most facilities also reported monthly meetings for executive committee members.
HFMCs, and particularly secretaries and chairmen, were generally reported to be committed to their duties, which they primarily described as linking the community to the health centre. Challenges reported included the need for more training on modalities of HSSF and their roles in its implementation, and some tension in relationships with in-charges.
Of interest is that only Only None of the 10 facilities where information on facility income was collected reported adhering to the user fee policy at the time of free care for under fives and KSH 20 for over fives Table 2 , although some did exempt children with malaria most urban facilities , children with pneumonia most rural and adults with Tuberculosis TB most rural. In qualitative interviews, urban health centres reported water, sanitation toilets and cleaners and minor renovations as their most important uses of HSSF funds, while rural facilities named casual labourers, essential drugs, food and referrals.
Interviews revealed some lack of clarity on whether HSSF funds could be used to buy drugs or hire accounting clerks.
Some expenses that were rejected by the DHMT, CBA or HSSF secretariat included newspapers, transport other than designated ambulances for referrals, major renovations, locum health workers and furniture. Potential consequences are known to include demotion, suspension, transfer, sacking and salary deductions, with these consequences described as contributing to some major anxiety and inaction among some staff. Beyond ineligible expenditure, there were some cases of misuse of funds such as user fee money being pocketed rather than recorded, a HFMC member taking a cash advance and then claiming to have been robbed, and an in-charge trying to forge signatures of HFMC members and transfer money to a personal account.
However, none of these cases were from the 10 health centres we visited, and in national interviews, we were informed that only 10 or so people throughout the country primarily DMOHs had suffered salary deductions for expenses that could not be explained. So it has made many things possible In-charge. More than three-quarters Approximately two-thirds reported improvements in facility cleanliness In-charges said there were more patients coming to the facility because of the availability of drugs and lab reagents for testing, the improved general condition of the facility, increased outreach programmes and affordable prices relative to private clinics.
However, this reduction in user fees was only reported in one facility; with most facilities maintaining user fees well above official levels as noted above.mistymomentszoo.com/3090.php
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Within this overall positive picture, challenges alluded to throughout the above results clearly had negative implications for quality of care and motivation of facility and management staff. These included the amount of paperwork, complaints about inadequate levels of funds at facility and district level, and debates about roles and functioning of committees, districts and CBAs.
There are important limits to our study design: we cannot generalize from our 10 purposively selected health facilities; we cannot quantitatively compare data from those facilities with an appropriate baseline or control group; and we did not measure technical quality of care. However, a number of important conclusions can be drawn.
Overall, experience with HSSF suggests that peripheral finance mechanisms can have important positive impacts on facilities in terms of ensuring that funds reach facilities, and that such funds can be overseen and used in a way that strengthens transparency and community involvement. HFMCs, one of the most widely introduced community accountability mechanisms across sub-Saharan Africa Molyneux et al.
Experience with HSSF also illustrates the possible positive impacts of a new finance mechanism on the wider health system. For example, the application of HSSF financial accountability systems to user fees reportedly strengthened community involvement in decision making for all facility funds, and reduced disputes between community representatives and frontline providers. These positive impacts were achieved through a finance mechanism in which funds are allocated across facilities based only on facility type, without any additional funding based on performance on key indicators.
This observation, also made for an in-depth post-hoc evaluation of the pilot of this initiative on the Coast Opwora et al. Within this overall positive experience, our evaluation of HSSF implementation suggests a range of further issues for consideration in selecting and evaluating periphery facility financing mechanisms in the region. One important challenge is the need to balance fiduciary oversight with administrative and monitoring burdens Witter However, HSSF experience illustrates the potential for these oversight mechanisms to undermine the initial intentions of a financing intervention.
HSSF was introduced to ensure that peripheral facilities gain access to funds allocated to them by cutting the bureaucracy involved, and enabling them to use their funds efficiently and in a transparent manner. In practice AIE processing is centralized, takes time and—importantly—ties down not only HSSF funds but also what were previously relatively flexibly used user fees.
Thus, there is a risk not only that gains from finance interventions are undermined, but also that there are broader unintended consequences. This may have reduced funding delays for facilities, but our data suggests that simplifying unnecessarily complex accounting procedures would also strengthen implementation. Administrative and monitoring burdens were minimized in HSSF by CBAs, who played a key support role for in-charges, including through working with them to develop a range of coping strategies and some local decision-making space and flexibility within guidelines.
The literature suggests that staff who interface between actors within a complex system with different interests, relationships, modes of rationality and power Helsinki ; Long , have the potential to translate and re-shape interventions on the ground, and to contribute to feeding frontline priorities and concerns upwards through the system to change the design and implementation. We suggest this potential is recognized and harnessed.