1. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Characteristics and Operation of Health Facility Committees in Kenya’s Primary Care Facilities: Readiness for HSSF and implications for promoting universal access Evelyn Waweru Antony Opwora, Mitsuru Toda, Tansy Edwards, Greg Fegan, Abdisalan Noor, Sassy Molyneux, Catherine Goodman

2. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 BACKGROUND  Community participation has re-emerged as a top priority in health service delivery in sub- Saharan Africa  Initiatives are focussed on the establishment of Health Facility Committees (HFCs) which bridge the gap between the facility and the community  In Kenya, the role of HFCs will be expanded with the introduction of the Health Sector Services Fund (HSSF)

4. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 HEALTH SECTOR SERVICES FUND  A nationwide GoK fund to support a sector wide approach to resources for primary care facilities  HSSF resources are credited directly to each designated facility’s bank account, and managed by the HFC  The HFC has 7-9 members, including at least 3 females:  4 catchment area residents (‘ordinary’ community members)  4 ex-officio members (health facility in-charge and representatives of: provincial administration; DMOH; and local authority facilities)  Committee prepares a work plan based on guidelines  Funds can cover operations and maintenance, refurbishment, support staff, allowances, utilities, community based activities  Enhances community/facility/district management communication

5. WITHOUT HSSF Treasury Money from the national treasury is given to MoPHS National MoPHS disburses money to the PHMT Provincial PHMT disburses money to the DHMT District DHMT decides on how and where funds should be used Facility Facility In-Charge requests for and sometimes gets funds from DHMT WITH HSSF Treasury Money from the national treasury is given to MoPHS National MoPHS disburses funds direct to facility accounts Facility HFC manages funds according to approved budgets and specific needs of the facility

6. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 STUDY OBJECTIVES Broad Objective – Collect and present nationally representative data on HFCs in Kenya in advance of the introduction of HSSF nationally Specific Objectives i. Document HFC characteristics and operations ii. Assess patient awareness of their activities iii. Describe roles and benefits of HFC members iv. Explore HFC members motivation and job satisfaction

7. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 STUDY DESIGN  Cluster randomized sample of facilities  Randomly selected 24 districts  Three non-municipal districts per Province (excl. Nairobi)  Three municipal districts  Selected random sample of facilities in each district, stratified by facility type  Facility sampling frame included all facilities eligible to receive HSSF  Selected up to 7 health centres and 7 dispensaries in each district

8. 8 DATA COLLECTION

9. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 DATA COLLECTION  Data collected: July – September 2010  Structured survey at each facility:  Interview with the facility in-charge  Self-administered questionnaire for the In- Charge on motivation and empowerment  Interviews with 2 HFC members  Exit interviews with 3 outpatients (curative care)  Collection of contextual data at the district level

10. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 DATA ANALYSIS  Used Stata v. 11 for cleaning and analysis  Used survey commands to account for:  Variation in sampling probability across facilities using pweights  Stratification by province and health facility type  Clustering at the district and facility level

11. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 SUMMARY OF DATA COLLECTED

13. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 KEY FINDINGS IN RELATION TO:  HFC membership, selection and characteristics, and training  Patient awareness of HFCs  Perceived roles of HFCs  HFC meetings, allowances, benefits and constraints  HFC/in-charge relationships  HFC motivation

14. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 HFC MEMBERSHIP AND SELECTION  97.2% of the facilities sampled had HFCs  Median of 10 members per HFC  23.3% HFCs included all types of members in the Government Gazette  58.8% joined the HFC between 1 and 5 years ago 18.5% in the last year  Most HFC members reported being selected at a Baraza (72.2%)

15. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 HFC MEMBERS’ CHARACTERISTICS  Age: all 25 years or over, with just over half aged 45 years or above  Occupation: mostly business/trade (25.6%) and subsistence farming (24.4%)  Education: half (53.2%) completed secondary school  Residence: Most (65.1%) lived less than 30 minutes walk away from the facility they served  Gender: 30.0% of all HFC members were female  CHW training: Just under half (44.8%) reported having been trained as community health workers

16. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 HFC MEMBER TRAINING  Training in facility/financial management:  In 26.7% of facilities, one or more health workers were trained (24.4% in non-municipal dispensaries to 82.4% in non-municipal health centres)  About half of HFC members (50.1%) reported having received training, slightly more in health centres than in dispensaries

17. Patient Awareness of HFCs

19. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 PERCEPTIONS OF HFC ROLES (CONT.) In-charges described HFC roles in similar ways, but only 34.5% considered supervision of facility staff an HFC role (as opposed to 61.9% of HFC members) Users of facilities often did not know HFC responsibilities. For example, many did not know whether it was HFCs’ role to: – Set the level of user fees (24.7% users) – Contribute to the development of annual work plans (22.3%) – Decide on how facility funds are utilized (19.3%)

20. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 HFC MEETINGS AND ALLOWANCES (IN-CHARGE RESPONSES)  Of facilities with HFCs:  77.9% held a full committee meeting in the last quarter (median n=1)  Half held smaller executive meetings (median n=1)  53.1% received allowances for full meetings; 29.5% received allowances for executive meetings  Median allowances where paid were KES 200

22. RELATIONSHIPS

23. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 RELATIONSHIP BETWEEN HFC MEMBERS AND THE IN-CHARGE: POSITIVE  > 80% of HFC members agreed/strongly agreed:  “It is useful to hear the views of the facility in-charge during HFC meetings”  “I believe that the in-charge works in the interest of this facility”  > 80% of in-charges agreed/strongly agreed:  “The health workers and the community members of the HFC work well together”  “If I have better knowledge, the HFC are willing to accept advice from me”

24. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 RELATIONSHIP BETWEEN HFC MEMBERS AND THE IN-CHARGE: CONCERNS  13.9% of HFC members and 47.9% of in-charges agreed with the following statement: “Tensions between the in-charge and committee members undermine the committee’s achievements”  11.5% of HFC members agreed with the statement: “The facility in–charge sometimes looks down on community members in the HFC”

27. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 SUMMARY  Presence of minimum requirements  Bank account  Health facility committees  HFC members awareness of their roles  Positive relationships : in- charges and HFC members  HFC seem highly motivated  Supportive supervision was not as frequent  HFC were not content with their allowances  Concern of some tension between in-charges and HFC members  Training Positive Findings Significant Challenges

28. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 SUGGESTIONS FOR FOLLOW-UP  Monitor and evaluate of HFCs functions (audit)  Sustainability: funding, HFC member incentives  Feasibility of performance based financing as a reward/incentive for high achieving facilities  Emphasis on community participation and reporting  HFC members ability to fully participate in HSSF planning and follow HSSF financial procedures

29. BETTER HEALTH BETTER DAYS