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Olago A, Suharlim C, Hussein S, Njuguna D, Macharia S, Muñoz R, Opuni M, Castro H, Uzamukunda C, Walker D, Birse S, Wangia E, Gilmartin C. The costs and financing needs of delivering Kenya's primary health care service package. Front Public Health 2023; 11:1226163. [PMID: 37900028 PMCID: PMC10613057 DOI: 10.3389/fpubh.2023.1226163] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 09/19/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction For many Kenyans, high-quality primary health care (PHC) services remain unavailable, inaccessible, or unaffordable. To address these challenges, the Government of Kenya has committed to strengthening the country's PHC system by introducing a comprehensive package of PHC services and promoting the efficient use of existing resources through its primary care network approach. Our study estimated the costs of delivering PHC services in public sector facilities in seven sub-counties, comparing actual costs to normative costs of delivering Kenya's PHC package and determining the corresponding financial resource gap to achieving universal coverage. Methods We collected primary data from a sample of 71 facilities, including dispensaries, health centers, and sub-county hospitals. Data on facility-level recurrent costs were collected retrospectively for 1 year (2018-2019) to estimate economic costs from the public sector perspective. Total actual costs from the sampled facilities were extrapolated using service utilization data from the Kenya Health Information System for the universe of facilities to obtain sub-county and national PHC cost estimates. Normative costs were estimated based on standard treatment protocols and the populations in need of PHC in each sub-county. Results and discussion The average actual PHC cost per capita ranged from US$ 9.3 in Ganze sub-county to US$ 47.2 in Mukurweini while the normative cost per capita ranged from US$ 31.8 in Ganze to US$ 42.4 in Kibwezi West. With the exception of Mukurweini (where there was no financial resource gap), closing the resource gap would require significant increases in PHC expenditures and/or improvements to increase the efficiency of PHC service delivery such as improved staff distribution, increased demand for services and patient loads per clinical staff, and reduced bypass to higher level facilities. This study offers valuable evidence on sub-national cost variations and resource requirements to guide the implementation of the government's PHC reforms and resource mobilization efforts.
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Affiliation(s)
- Agatha Olago
- Kenya Ministry of Health, Department of Primary Health Care, Nairobi, Kenya
| | - Christian Suharlim
- Management Sciences for Health, Medford, MA, United States
- Management Sciences for Health, Health Economics and Financing, Arlington, VA, United States
| | - Salim Hussein
- Kenya Ministry of Health, Department of Primary Health Care, Nairobi, Kenya
| | - David Njuguna
- Kenya Ministry of Health, Health Economist, Nairobi, Kenya
| | - Stephen Macharia
- Kenya Ministry of Health, Director of Planning, Chief Economist and Head of Planning, Nairobi, Kenya
| | | | | | - Hector Castro
- Management Sciences for Health, Medford, MA, United States
- Management Sciences for Health, Health Economics and Financing, Arlington, VA, United States
| | - Clarisse Uzamukunda
- Management Sciences for Health, Medford, MA, United States
- Independent Consultant, Kigali, Rwanda
| | - Damian Walker
- Management Sciences for Health, Medford, MA, United States
- Management Sciences for Health, Health Economics and Financing, Arlington, VA, United States
| | - Sarah Birse
- Management Sciences for Health, Medford, MA, United States
- Management Sciences for Health, Health Economics and Financing, Arlington, VA, United States
| | - Elizabeth Wangia
- Kenya Ministry of Health, Department of Health Financing, Nairobi, Kenya
| | - Colin Gilmartin
- Management Sciences for Health, Medford, MA, United States
- Management Sciences for Health, Health Economics and Financing, Arlington, VA, United States
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Kachapila M, Kigozi J, Oppong R. Exploring the roles of players in strategic purchasing for healthcare in Africa-a scoping review. Health Policy Plan 2022; 38:97-108. [PMID: 36318330 PMCID: PMC9849715 DOI: 10.1093/heapol/czac093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2022] Open
Abstract
Following the World Health Organization (WHO) guidance on strategic purchasing in 2000, low- and middle-income countries (LMICs) are trying to shift from passive purchasing (using fixed budgets) to strategic purchasing of healthcare which ties reimbursement to outcomes. However, there is limited evidence on strategic purchasing in Africa. We conducted a scoping literature review aimed at summarizing the roles played by governments, purchasers and providers in relation to citizens/population in strategic purchasing in Africa. The review searched for scientific journal articles that contained data on strategic purchasing collected from Africa. The literature search identified 957 articles of which 80 matched the inclusion criteria and were included in the review. The study revealed that in some countries strategic purchasing has been used as a tool for healthcare reforms or for strengthening systems that were not functional under fixed budgets. However, there was some evidence of a lack of government commitment in taking leading roles and funding strategic purchasing. Further, in some countries the laws need to be revised to accommodate new arrangements that were not part of fixed budgets. The review also established that there were some obstacles within the public health systems that deterred purchasers from promoting efficiency among providers and that prevented providers from having full autonomy in decision making. As African countries strive to shift from passive to strategic purchasing of healthcare, there is need for full government commitment on strategic purchasing. There is need to further revise appropriate legal frameworks to support strategic purchasing, conduct assessments of the healthcare systems before designing strategic purchasing schemes and to sensitize the providers and citizens on their roles and entitlements respectively.
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Affiliation(s)
- Mwayi Kachapila
- *Corresponding author. Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. E-mail:
| | - Jesse Kigozi
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Raymond Oppong
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Kabia E, Kazungu J, Barasa E. The Effects of Health Purchasing Reforms on Equity, Access, Quality of Care, and Financial Protection in Kenya: A Narrative Review. Health Syst Reform 2022; 8:2114173. [PMID: 36166272 DOI: 10.1080/23288604.2022.2114173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Kenya has implemented several health purchasing reforms to facilitate progress toward universal health coverage. We conducted a narrative review of peer-reviewed and grey literature to examine how these reforms have affected health system outcomes in terms of equity, access, quality of care, and financial protection. We categorized the purchasing reforms we identified into the areas of benefits specification, provider payment, and performance monitoring. We found that the introduction and expansion of benefit packages for maternity, outpatient, and specialized services improved responsiveness to population needs and enhanced protection from financial hardship. However, access to service entitlements was limited by inadequate awareness of the covered services among providers and lack of service availability at contracted facilities. Provider payment reforms increased health facilities' access to funds, which enhanced service delivery, quality of care, and staff motivation. But delays and the perceived inadequacy of payment rates incentivized negative provider behavior, which limited access to care and exposed patients to out-of-pocket payments. We found that performance monitoring reforms improved the quality assurance capacity of the public insurer and enhanced patient safety, service utilization, and quality of care provided by facilities. Although health purchasing reforms have improved access, quality of care, and financial risk protection to some extent in Kenya, they should be aligned and implemented jointly rather than as individual interventions. Measures that policymakers might consider include strengthening communication of health benefits, timely and adequate payment of providers, and enhancing health facility autonomy over the revenues they generate.
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Affiliation(s)
- Evelyn Kabia
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacob Kazungu
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Barasa E, Mathauer I, Kabia E, Ezumah N, Mbau R, Honda A, Dkhimi F, Onwujekwe O, Phuong HT, Hanson K. How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them. Health Policy Plan 2021; 36:861-868. [PMID: 33948635 PMCID: PMC8227448 DOI: 10.1093/heapol/czab003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/14/2022] Open
Abstract
Provider payment methods are a key health policy lever because they influence healthcare provider behaviour and affect health system objectives, such as efficiency, equity, financial protection and quality. Previous research focused on analysing individual provider payment methods in isolation, or on the actions of individual purchasers. However, purchasers typically use a mix of provider payment methods to pay healthcare providers and most health systems are fragmented with multiple purchasers. From a health provider perspective, these different payments are experienced as multiple funding flows which together send a complex set of signals about where they should focus their effort. In this article, we argue that there is a need to expand the analysis of provider payment methods to include an analysis of the interactions of multiple funding flows and the combined effect of their incentives on the provision of healthcare services. The purpose of the article is to highlight the importance of multiple funding flows to health facilities and present a conceptual framework to guide their analysis. The framework hypothesizes that when healthcare providers receive multiple funding flows, they may find certain funding flows more favourable than others based on how these funding flows compare to each other on a range of attributes. This creates a set of incentives, and consequently, healthcare providers may alter their behaviour in three ways: resource shifting, service shifting and cost shifting. We describe these behaviours and how they may affect health system objectives. Our analysis underlines the need to align the incentives generated by multiple funding flows. To achieve this, we propose three policy strategies that relate to the governance of healthcare purchasing: reducing the fragmentation of health financing arrangements to decrease the number of multiple purchaser arrangements and funding flows; harmonizing signals from multiple funding flows; and constraining providers from responding to undesirable incentives.
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Affiliation(s)
- Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Inke Mathauer
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Evelyn Kabia
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Nkoli Ezumah
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Rahab Mbau
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ayako Honda
- Research Center for Health Policy and Economics at the Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Japan
| | - Fahdi Dkhimi
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Hoang Thi Phuong
- Health Strategy and Policy Institute, Ministry of Health, Hanoi, Vietnam
| | - Kara Hanson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Tangcharoensathien V, Mills A, Patcharanarumol W, Witthayapipopsakul W. Universal health coverage: time to deliver on political promises. Bull World Health Organ 2020; 98:78-78A. [PMID: 32015572 PMCID: PMC6986228 DOI: 10.2471/blt.20.250597] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
| | - Anne Mills
- London School of Hygiene and Tropical Medicine, University of London, London, England
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