Photo credit: World Bank/Sarah Farhat
The Government of Kenya is committed to improve RMNCAH outcomes and set a path for achieving Universal Health Coverage (UHC). The new policies and initiatives of the Government such as “Free Maternity Care”, “Beyond Zero” and the “elimination of user fee for primary healthcare” clearly highlight that RMNCAH remains a key development priority for Kenya. The 2014 Kenya Demographic and Health Survey (KDHS) shows improvements in most RMNCAH indicators from 2008: skilled birth attendance increased from 44 percent to 62 percent in 2014 and under-five mortality dropped from 74 to 52 per 1000 live births. Despite such progress, Kenya will not be able to achieve its Millennium Development Goals for maternal and child health. Economic and geographic disparities persist and challenges in health service delivery remain. Moreover, heavy reliance on out-of-pocket expenditure, fragmented public and private funds as well as a high degree of dependency on donor assistance – much of which supports disease-specific initiatives -- continues to constrain the attainment of results.
RBF AT A GLANCE
The Kenya Health Sector Support Project uses Results-Based Financing (RBF) to increase the delivery, use and quality of maternal and child health services. Under this scheme, primary health facilities are contracted by County Departments of Health to achieve pre-defined results in maternal and child health services and HIV-related services in 21 arid and semi-arid (ASAL) counties. Health facilities are paid by the County Departments of Health (i.e. the county fund holder) for selected maternal and child health services provided adjusting for the quantity and quality from a special purpose account which receives transfers from the national level through the county revenue fund. Forty percent of RBF payments are typically used to improve service delivery – including minor infrastructure improvements, equipment and supplies – and 60 percent are used as performance incentives for healthcare personnel, community health workers and supporting staff.
The Ministry of Health (MOH) leads the RBF regulation function, ensuring compliance with RBF objectives and principles and alignment with national norms and guidelines.
The RBF verification function is led by the County Department of Health. The verification of the quantity of services is carried out quarterly by a Joint Verification Team (JVT), including representatives from the County Department of Health, partner non-governmental organizations, and county hospitals. During verification visits, the JVT reviews the health facility’s records to ensure the consistency and accuracy of reported data. During the same visit, a quality checklist is administered to assess the technical quality of services delivered. In addition, an independent integrated fiduciary review agent (IIFRA) carries out a semiannual independent review of financial transactions at sampled primary healthcare facilities including physical verification of results and payments made for health outputs under RBF.
Status and achievements
The RBF approach adopted and implemented in Kenya was initially piloted in Samburu County in 2011. Based on the encouraging results yielded by this pilot project, the Government of Kenya decided to scale-up RBF to 21 counties. Scaling up started in January 2016, once a national framework for the transfer of conditional grants was created.
The recent devolution adds challenges to the task of ensuring that RBF implementation functions, roles, and responsibilities are clearly defined. Further, while the mechanism for intergovernmental fund transfers has recently been created and funds are flowing from national to county level, some challenges still remain in the movement of funds within the country. In particular, a few counties have not opened the special purpose account which is a ring-fenced account for conditional grants for health. Further, the newly formed county governments have capacity limitations to effectively perform their responsibilities in implementation and require substantial implementation support. To facilitate this, the MOH is convening semiannual workshops with all 21 counties and undertaking regular field visits to find solutions for implementation challenges including for cross-county learning.
- Piloting an RBF approach enables to test and refine project design, providing a strong momentum for expansion in the event of positive and encouraging pilot results.
- Scaling-up RBF in a devolved environment requires effective engagement of stakeholders at all levels, including at devolved levels throughout implementation.
- Scaling-up RBF requires a dedicated team at the national level to manage the process effectively.