Robinson Karuga is research coordinator at FCI-Kenya.
In Kenya, when someone in a poor, rural community needs health care, she goes to a health center — a facility in a nearby market town, offering a broad range of primary health services — or to a dispensary — a lower-level facility, typically staffed by a single nurse and providing only limited services. For most Kenyans, health centers and dispensaries are their only contact with the health system, and the only available source of primary care. For Kenya to make meaningful progress in reducing its high rates of maternal and child mortality, the services offered in these primary-level facilities must be strengthened, and more Kenyans must be persuaded to use them: more than half of Kenyan women still give birth without help from a skilled attendant, a statistic that has actually become worse over the past 20 years.
Unfortunately, primary-level facilities often have not had the money they need to support consistent, high-quality services — in Kenya’s centralized national health system, allocated funds rarely filtered down to facilities through inefficient district disbursement channels characterized by leakages and mismanagement. In recent years, this funding shortfall was made worse by the government’s reduction and ultimate abolition of official user fees for many essential health services: ironically, a policy designed to increase poor people’s access to services often resulted in poorer service quality, as the facilities’ lost revenue was not replaced.
Beginning in 2010, the Ministry of Health addressed this problem with a program of ‘Direct Facility Funding’ (DFF), by which funds are provided directly from the national government to cover facilities’ core expenses, so that they can provide high-quality services that are responsive to communities’ needs. This is a potentially powerful reform, but facilities face significant challenges in implementing it, including managers with insufficient budgeting and money management skills and a lack of transparency in how money is allocated and spent. There is also a lack of community awareness and monitoring of the DFF process, which minimizes community input on priorities for quality‐of‐care improvements.
This year, with support a from the Transparency and Accountability Program of the Results for Development Institute, FCI-Kenya will evaluate communities’ knowledge and understanding of the direct facility funding system and their level of satisfaction with health facilities’ quality of service and accountability. FCI will work in two counties (one rural and one urban), using “citizen report cards” to collect quantitative and qualitative data from health facility clients and from members of Health Facility Management Committees, community-based groups that are charged with managing funds at the facility level.
FCI will then work with government partners to develop an advocacy and community mobilization strategy to provide Health Facility Management Committee members with the knowledge and skills to manage funds effectively, and to ensure that community members have input into how funds are spent. Based on lessons learned from the project, the Ministry of Health — which enthusiastically supports this first-ever evaluation of the DFF reforms —plans to introduce the citizen report card throughout the country. It will serve as a continuous social accountability tool, creating a feedback loop between the national health financing structure and the community, and giving users of the health system a real voice in the services it provides. By empowering communities and building financial management capacity in the facilities themselves, this project offers a new and meaningful opportunity both to improve the quality of care and to increase demand for high-quality services.