CASE STUDIES
FOR
HEALTH SYSTEMS AND
POLICY ANALYSIS
CASE STUDY ON HEALTH SYSTEMS GOVERNANCE AND FINANCING
Health Facility Committees and Financial Management
Structures in Kenya - Participants’ Guide
CHEPSAA case studies for health policy and systems analysis
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The development of sustained African health policy and systems research and teaching capacity requires the
consolidation and strengthening of relevant research and educational programmes as well as the development
of stronger engagement between the policy and research communities. The Consortium for Health Policy and
Systems Analysis in Africa (CHEPSAA) will address both of these issues over the period 2011 - 2015.
CHEPSAA’s goal is to extend sustainable African capacity to produce and use high quality health policy and
systems research by harnessing synergies among a Consortium of African and European universities with
relevant expertise. This goal will be reached through CHEPSAA’s five work packages:
1.
2.
3.
4.
5.
assessing the capacity development needs of the African members and national policy networks;
supporting the development of African researchers and educators;
strengthening courses of relevance to health policy and systems research and analysis;
strengthening networking among the health policy and systems education, research and policy
communities and strengthening the process of getting research into policy and practice;
project management and knowledge management.
The CHEPSAA project is led by Lucy Gilson (Professor: University of Cape Town & London School of Hygiene
and Tropical Medicine).
PARTNERS
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Health Policy & Systems Programme, the Health Economics Unit, University of Cape Town, South Africa
School of Public Health, University of the Western Cape, South Africa
Centre for Health Policy, University of the Witwatersrand, South Africa
Institute of Development Studies, University of Dar es Salaam, Tanzania
School of Public Health, University of Ghana, Legon, Ghana
Tropical Institute of Community Health, Great Lakes University of Kisumu, Kenya
College of Medicine, University of Nigeria Enugu, Nigeria
London School of Hygiene & Tropical Medicine, United Kingdom
Nuffield Centre for International Health and Development, University of Leeds, United Kingdom
Karolinska Institutet, Sweden
Swiss Tropical and Public Health Institute, University of Basel, Switzerland
CHEPSAA WEBSITE
www.hpsa-africa.org
ACKNOWLEDGEMENTS
An acknowledgement is given to all CHEPSAA partners who contributed to the course development process.
SUGGESTED CITATION
CHEPSAA. (2014). Introduction to Complex Health Systems: Case Study materials. CHEPSAA
(Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org
This document is an output from a project funded by the European
Commission (EC) FP7-Africa (Grant no. 265482). The views expressed
are not necessarily those of the EC.
CHEPSAA case studies for health policy and systems analysis
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A Case Study on Health Systems Governance and Financing:
Health facility committees and financial management structures in
Kenya
There are a number of goals or objectives we would like you to achieve through doing this
case study, as listed below:
Learning Objectives of the case study
 Identify the key agents in the case and describe their relationships within the health
system, as part of the socially constructed nature of the health system.
 Identify the key contextual features of this case
 Analyse the mindsets, interests, power and agency of key agents in the situation.
 Analyse how the introduction of Direct Facility Funding impacted on the existing
relationships among agents, and is itself affected by those reactions.
 Identify intended and unintended consequences of the new policy.
 Suggest alternative strategies that could have been used to strengthen the
intervention, using systems thinking and taking into consideration both hard and soft
aspects of the health system.
 Plan and deliver a group presentation, using effective groupwork and
communication skills.
Tasks
After reading the case study narrative (pages 8 - 13 of this handout), do tasks A – D below in
your small groups, in preparation for a 20 minute presentation about the case study which
should cover the following:
A. Overview of the case (5 minute presentation) – to include:
1. Key features of the case – Draw a flow diagram showing the main drivers and events
of the case and how each stage had consequences, some of which were not
intended.
2. Context of the case study - Complete the context analysis form on page 4 identifying
the key features of this particular case and how they have contributed to the
situation.
B. Identify the hardware and software issues and elements which are most important in
shaping this case, using guidance from Aragon’s framework below, and explain how they are
linked and interact. (5 minute presentation)
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Understanding organisa ons
Hardware:
Organisa onal
hierarchy
HR establishment
Tangible so ware:
Management
knowledge and
skills
Intangible so ware:
capabili es to commit and
engage; adapt & self-renew;
balance diversity and coherence
Technology
Formal
management
processes
Finance
Values & Informal
rules
norms
Rela on- Commships
unica on
adapted from Aragon, 2010
C. Stakeholder analysis. Identify the key agents in the case and, situating them in the time
when the DFF scheme had just been introduces, map these in diagram 1, (you can also use
Form 1 on page 5 below to help your analysis) according to their levels of commitment and
power to impact on successful implementation of the change. Draw lines between agents
who have a close relationship with each other (e.g. through flow of money or information,
lines of command or support). Consider how their position on the map changed over time,
and be prepared to explain this, as well as agents’ mindsets and levels of power, and how
agents are related to each other. (5 minute presentation)
D. Leading and managing change. Put yourselves in the position of a Facility Management
Nurse (FMN) in the case. You are well-acquainted with the challenges of implementing the
intervention and are looking for support for the changes. As this facility-level leader, think
about how you can improve already quite successful implementation and act against the
practice of continuing to charge high user fees. Using the concepts and frameworks you
have been introduced to in the course, above and in the session 7 lecture on ‘Leadership of
change in health systems’, design 3 strategies to increase other agents’ understanding and
buy-in – particularly HFC members and communities. These could include small wins. In
developing strategies also think of the ideas raised in the Duncan Green video. (5 minute
presentation)
On the next two pages are templates you can use for your Context and Stakeholder Analysis.
In preparing your presentation consider the following:
 Consider your audience, and design the presentation so that the level, language and
content are appropriate for them;
 Make sure you have covered all the necessary/important information;
 Organise your points/ideas in a logically and clearly structured way;
 Introduce the presentation with an attention catching question or comment, and a brief
preview of the content;
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The body of the presentation should have clear main and sub-points;
Keep to the allocated time (if possible ask a colleague to check the timing for you);
Speak clearly and not too fast;
Conclude the presentation with a brief re-statement of the main points or a
summarising comment.
You will use these criteria for assessing the group presentations:
Assessment criteria
The overview of the case is clear and succinct and gives a clear image of what the case is about.
The hardware and software issues at play in the case, and their relationship, are clearly explained.
The roles of actors, their mindsets, interests and power are presented and explained convincingly.
The suggested strategies for leading change are well motivated.
Delivery of the presentation (visual and oral) is clear, using appropriate pace and level, and content
is coherently and logically structured.
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Contextual feature
Specific issues relevant to this experience
(remember not all issues might be relevant
to this case)
Impact of these issues on actors (name these) and the case, and
implications for policy implementation
Micro context
organisational
climate & culture
other policies
organisational
capacity
interpersonal factors
Macro context
social & political
pressures &
interests
historical & sociocultural context
economic conditions
& policy
international
context
environmental
factors
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Form 1. Unpacking agent behavioural drivers and power
AGENT
Mindsets, values and interests
What are the core elements of the
agent’s ‘mindset’ (beliefs, values
driving behaviour in general?)
CHEPSAA case studies for health policy and systems analysis
Forms and level of power to influence implementation
Given the elements identified in
column 1, is actor’s response to
the change likely to be committed,
compliant, indifferent, resistant,
or hostile?
What forms of power can the agent
mobilise to support his/her actions
around the new policies?
What power limits does the actor face in
taking action around the new policies?
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Diagram 1: Agent map
Low <<---------------------Power------------------->>.High
Locate your actors on this map of support and opposition for change, taking account of their power level
Very committed << compliant << indifferent >> resistant >> hostile
Commitment
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Health Facility Committees and financial management: A
Kenyan case study
Narrative
Background
This case study examines the implementation of two policies in Kenya aimed at health
system strengthening. The first is Health Facility Committees (HFC’s) - an approach to
broadening community participation in public health service delivery; and the second Direct
Facility Funding (DFF) - a mechanism for transferring health funding to the periphery of the
health system.
From the 1980’s, various approaches were taken by Kenyan authorities towards reforming
the health system, with the aim of leveraging improvement in utilisation and quality of care
of health services. Community participation and decentralisation were important drivers of
these reforms.
Below is a timeline showing the development of some relevant reforms over the period
covered in the case study:
1980’s
Introduction of user fees to provide more revenue and
therefore better health services in public health facilities;
Introduction of Health Facility Committees with responsibility
for disbursing most of the user fee revenue.
1998
Health Facility Committees (HFC) officially established, with
prescribed roles and responsibilities, supported by funds from
the Ministry of Health and the Danish International
Development Agency (DANIDA)
2004
User fees reduced to widen access to public health services;
however this reduced facilities’ revenue and therefore their
capacity for providing services.
2004
Direct Facility Funding (DFF) scheme introduced to channel
more revenue from central government to health facilities, to
make up for loss of income from reduction of user fees. The
scheme was piloted in Coast Province.
2005
Role of HFC’s expanded to include management of facility
budgets under the DFF scheme
2007 - 2009 Government regulation regarding roles and functions, and
composition of HFC’s
2010 - 2012 National roll-out of HFC’s for public health centres and
dispensaries, based on perceived success of pilot
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Health Facility Committees
The Kenyan government officially established Health Facility Committees in 1998, as a
contribution towards building community accountability in public health.
Their roles were defined as follows:
Roles of the HFC
1. To oversee the general operations and management of the health facility
2. To advise the community on matters related to the promotion of health services
3. To represent and articulate community interests on matters pertaining to health in local
development forums
4. To facilitate a feedback process to the community pertaining to the operations and management
of the health facility
5. To implement community decisions pertaining to their own health
6. To mobilise community resources towards the development of health services within the area
Powers of the HFC
1. The committee shall have the authority to raise funds from within itself, the community or from
donors and other well-wishers for the purpose of financing the operations and maintenance of the
facility
2. The committee shall have authority to hire and fire subordinate staff employed by itself in the
health facility
3. The committee shall oversee the development and expansion and maintenance of the physical
facilities within their respective area
Source: Managing a Health Facility: A Handbook for Committee Members and Facility Staff. Ministry
of Health & Aga Khan Health Service, Kenya, Second Edition, 2005 [13]
Committee members included the health worker in-charge of the health facility as secretary
and between 8 and 18 community members. The chair and the treasurer were chosen from
the community members. Most of the latter were farmers, though some were professionals
such as teachers, and a few were community health workers. A few committees had Area
Chiefs and Councilors as members by virtue of their official role. All committees had at least
one female member as required by DFF guidelines.
All HFCs had a constitution which outlined rules and codes of conduct regulating committee
functioning, such as frequency of meetings.
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HFC’s were to be supported and strengthened by management training provided by the
Ministry of Health and DANIDA Health Services project. In 2005 the roles of the HFC’s were
expanded to include management of budgets and funds under the DFF scheme.
Direct Facility Funding (DFF) scheme
Prior to 2004 primary health care services had two sources of funding: resources for
infrastructure, drugs, medical supplies and staffing had been supplied by the Ministry of
Health (later called the Ministry of Public Health and Sanitation), but these had often not
‘trickled down’ to facilities as intended: in some cases barely 30% of funding made it to
small facilities. The only other income available to health facilities was that gathered from
user fees and other income generating schemes such as the sale of mosquito nets. However,
there had been pressure for the abolition or reduction of health facility user fees, as these
had been seen as a barrier to health access for the poor.
In 2004, Kenya removed high and variable user fees for health facilities, replacing them with
flat rate fees of KES 10 (approximately US$ .15) at dispensaries, and KES 20 (approximately
US$ .30) at health centres.
In response to concerns that these lower fees limited the money available to health facilities
for daily expenditures, the Kenyan Government and the Danish International Development
Agency (DANIDA) piloted an innovative scheme of directly funding health facilities in one
province in Kenya (Coast Province): Direct Facility Funding (DFF).
With direct facility funding, health facilities receive money directly into their bank account.
All health facilities with qualified staff were eligible for DFF, which was to be allocated
according to a set of criteria based on workload and facility type. Another key provision for
participation in the DFF scheme was that facilities comply with the national policy on
reduced user fees.
The funds are managed by the Health Facility Committee. DFF supervision was provided by
the District Health Management Team (DHMT), with the team members most involved
being the facility management nurse (FMN) and the district accountant. Additional oversight
was provided by two provincial level accountants.
The post of FMN was created to support links between facilities, the community and the
district by strengthening the management of committees. This involved overseeing the
selection of committee members, organizing training, and assisting committees in planning
and continuously evaluating those plans.
The items on which DFF could be used included: salaries, water and electricity supplies,
communications, staff travel costs, office and general supplies and routine maintenance of
vehicles, equipment and buildings. The wage bill could not exceed 30% of disbursed funds,
and expenditure on HFC allowances and drugs was not allowed. The Government continued
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to cover the vast majority of facility resources through in kind provision of infrastructure,
trained health workers, supervision, drug kits and medical supplies. HFCs budgeted for the
DFF funds within specific guidelines, implemented work plans and kept accounts.
In the years following implementation the average annual income from DFF was US$4,720
and US$2,802 per health centre and dispensary, respectively. This accounted for an average
of 56% of the facilities’ annual income. The remainder continued to be made up of user
fees, sale of insecticide treated nets, income generating activities and donations. Despite
the DFF funds, it was clear that facilities were not adhering to the user fees policy. Many
continued to levy charges above the prescribed fees and failed to exempt groups of patients
such as the under-fives and those with malaria. This was attributed to lack of official
communication of the policy and the need for more resources at the facility level.
Implementation of the DFF scheme
Evaluations of the pilot phase of DFF implementation found that HFC’s were in place and
functioning in most facilities, with meetings being held regularly and sitting allowance
generally being paid to members. HFC’s had existed before the initiation of the DFF but had
been less effective and active, and the funding they had controlled had been far less. DFF
provided the means for better participation, through payment of allowances, and greater
sense of ownership of the health facility. The following quote illustrates the thoughts of a
health worker in this regard.
‘‘You know management without finance is not management at all. Now if it couldn’t be
this DANIDA [DFF] funds these committees couldn’t be meeting often like that because
they would have nothing to discuss about or to budget for.’’ (Health worker)
The availability of money to pay allowances for attendance at meetings also increased
participation and made the committees more viable, although members continued to see
their roles as largely voluntary, and complained that allowances only partly recompensed
them, and should be increased. It was important for them to feel rewarded – with both
financial and non-financial incentives. The quote below is an example of members’ thinking
related to this:
“Previously, we depended on the cost, sharing money only and it was too little,
just enough for drugs or syringes but not allowances...members would not come for
meetings because there were no allowances.” (HFC member, Tana River)
HFC members were happy with the opportunities they had for training and to participate in
outreach programmes and health campaigns. They were sometimes allowed waivers on
their health facility user fees, and given priority treatment, which added to job satisfaction
in their HFC roles. Most were highly motivated and proud of to be HFC members.
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Relationships: HFC and health workers
There was generally cooperation between HFC’s and health workers, who valued the
opportunity to discuss issues with HFC community members and were happy with their
participation. Likewise, many HFC members expressed trust towards health workers and the
in-charge:
“In this committee we really trust our in-charge; the in-charge is very co-operative.
But in other areas, this may not be the case...” (HFC member, Kwale)
As hinted at in the quote above however, some health workers were not trusted, and were
thought to be hiding financial information from the committee. In other cases, as cited
earlier, HFC members were seen as ‘watchdogs’ and a ‘nuisance’ by health workers, taking
their supervisory role too seriously, undermining them and encroaching on their
professional space.
There was some disagreement on what decisions HFC’s were able to take with regard to
allocation of funds and management of the facility, and when they should be consulted on
issues. This lack of clarity added to tensions between members and facility staff, with
lengthy debates among committee members about the extent of their autonomy in some
areas. Some HFC community members also experienced tension with regard to the
oversight role given to in-charges and District Health Management Teams, who they felt
constrained their ability to manage facilities and make decisions on certain issues.
Some difficulties arose around the low education levels of community elected members
(47% of community members had not completed secondary education and some were
illiterate), which meant they could not grasp the necessary concepts or perform the
required functions of the committee.
One manager expressed this concern as follows:
“So you can imagine teaching financial issues, all those regulations, bar lines
and cash books to people who probably went to school up to say class 7, or
class 6 somewhere there, it really takes long for them to grasp the concept. ”
On the other hand more educated, professional members tended to intimidate others on
the committee. Both of these factors contributed to tensions in the HFC’s operation.
With the scale-up and introduction of the DFF scheme however, new guidelines were
gazetted for HFC’s which attempted to address the difficulties by restricting the number of
community members on a committee to 5, one of whom must have knowledge and
experience of finance and administration. The rest of the committee was to be made up of
nominated members (facility in-charge, and representatives of provincial administration,
District Medical Officer for Health and area councillor). The number of women required on a
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committee was changed from one to three, which improved the representation of
vulnerable groups - still an issue for consideration.
A positive role was often played by the Facility Management Nurses (FMN), who supported
the committees, built links between them and communities, guided them and resolved
disputes.
Relationships between the facility in-charge and community members of the HFC were also
noted to have improved since inception of the DFF, and in-charges tended to value the
opportunity to discuss issues with community members and appreciated the local legitimacy
given to the decisions of the HFC. Staff members were positive about the DFF despite the
extra supervisory work it entailed for them, for which they did however receive extra pay.
HFC members generally valued the support given to them by facility in-charges, nurses,
district accountants and facility staff, which helped empower them to fulfil their DFF
responsibilities.
Relationships: HFC and the wider community
Relationships between HFC’s and communities, like those between HFC’s and health
workers, were also considered to be good overall, with communities happy to have
representatives in the health facilities, and HFC members happy with the legitimacy of their
representation. There was however found to be low awareness of HFC’s, their role, function
and membership among outpatients interviewed, and significantly, very few (only 4%) had
actually raised a health issue with an HFC member. Awareness was found to be higher
among better educated and male interviewees.
Politics in the community played a part in HFC’s at times, with political aspirants in some
cases forcing HFC members to resign in order to elect their own supporters in their places.
There were also reports of some members spreading rumours about others with regard to
handling of funds, in order to create tensions or force resignations. Another problem was of
community members making inappropriate demands on HFC members with regard to
funds, as illustrated below:
“...once they heard the facility was receiving some money, the community wanted
us to make contributions to community projects...they do not understand that the
money is used within guidelines...” (HFC Member, Tana River)
A negative spin-off of conflicts which emerged between communities and HFC’s, was that
they often had to be defused by the nurse in-charges, placing an additional burden on them.
There was an apparent need to improve the links between HFC’s and the community they
represent, and accountability to them, as well as better communication in order to build
trust and transparency in the selection of committee members, roles, powers and functions
of the committees, and financial accounting.
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Outcomes of DFF process
HFC’s eventually managed to disburse about 80% of funds they managed, with the pattern
of spending across sites evaluated being similar – the majority being spent on travel and
wages for support staff. It was felt that allocations for drugs should have been allowed, as
centrally provided drug supplies were insufficient, but according to the guidelines this was
not allowed.
A common perception was that DFF had motivated health workers and improved their
performance, with reasons being that they had more access to resources – more support
staff to back their work; more funds to pay utility bills and buy non-drug supplies; and more
travel allowance available to facilitate outreach work.
It was expected that the additional funds from DFF would enable facilities to implement the
fee reductions and exemptions gazetted earlier, but this was found not to be the case.
Facilities were still over-charging clients, claiming that the DFF funds were insufficient to
cover all running costs. As exempted categories such as malaria patients, pregnant women
and under-5 children formed the bulk of their clientele, they could not function without user
fee income. The communication from the Ministry of Health regarding the user fee
reduction regulations were apparently also not clearly or formally conveyed, and therefore
this was given as a reason for non-compliance.
Although HFC members saw themselves as providing an important link between the
community and the health facility, it was found that only 46% of exit interviewee patients
from the facilities knew about the existence of the committees’ role in DFF, and even fewer
were aware of their composition or selection process, or knew any of the individual
members of the committees. There was also some evidence of suspicion towards the HFC by
community members regarding the handling of DFF funds, leading to tensions with other
members, as illustrated in the following quote:
‘‘. . . The treasurer resigned. . . he was fed up with the rumours that
money was being ‘eaten’. . .’’ (Health worker)
Part of the reason for poor relationships between HFC’s and communities they represented
was inadequate communication of information about the role and function of the HFC in
relation to DFF. For example, blackboards were supposed to be available in facilities with
information about the HFC and DFF, to enhance transparency, but these were seldom fully
completed or user-friendly, and were not effective in communities with high illiteracy rates.
Despite such negative aspects, the perceived impact of the DFF on quality of care and
increased utilisation of services was felt to be positive overall. This was mainly as a result of
increased health worker motivation, facilitated by increased revenue which enabled
employment of more support staff, improved drug supplies and infrastructure, reduced
waiting times, and better safety and cleanliness, all leading to improved working conditions
and reduced fatigue for staff, and better service delivery for clients. More revenue also
CHEPSAA case studies for health policy and systems analysis
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enabled extended opening hours at some facilities and an increase in outreach activities,
and thus greater coverage and reach of services such as immunisation, ante-natal care and
health education for the community.
One study (Opwora et al, 2009) demonstrated that DFF can be a successful mechanism for
transferring funds to the health system periphery, through active, representative and
reasonably effective HFC’s. Despite DFF funds making a relatively small contribution to
facilities’ revenue streams and user fees still being an important source of income, DFF had
a useful, though limited impact on health service delivery in Coast Province.
Readiness for the reforms to be taken forward
It was felt that the results of the study carried out in Coast Province were unlikely to be
generalizable to other provinces in Kenya currently, as they did not have the benefit of
FMN’s in place in health facilities or the comprehensive donor support for health
strengthening projects which were in place in Coast Province.
The studies found some level of preparedness for HFC’s to take on broader financial roles
through the DFF (now called Health Sector Services Fund – HSSF) and for the mechanisms to
be rolled out nationally across Kenya; however there were many apparent challenges that
might limit the potential to improve quality and utilisation of health services through the
wider implementation of these reforms. These challenges need to be addressed going
forward.
This case study is based on the following sources:
Waweru, E., Opwora, A., Toda, M., Fegan, G., Edwards, T., Goodman, C. & Molyneux, S.
(2013). Are Health Facility Management Committees in Kenya ready to implement financial
management tasks: findings from a nationally representative survey. BMC Health Serv Res.
2013 Oct 10;13:404.
Opwora, A., Kabare, M., Molyneux, S., Goodman, C. (2010) Direct facility funding as a
response to user fee reduction: implementation and perceived impact among Kenyan health
centres and dispensaries. Health Policy Plan. 2010 Sep;25(5):406-18.
Goodman, C., Opwora, A., Kabare, M., Molyneux, S. (2011) Health facility committees and
facility management - exploring the nature and depth of their roles in Coast Province,
Kenya. BMC Health Serv Res. 2011 Sep 22;11:229.
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