Background: Direct facility funding (DFF) is an initiative that was developed in response to concern that Ministry of Health funds allocated to districts rarely filter down to the health centres and dispensaries, and that these facilities have also lost revenue due to the reduction in official user fees in 2004. Piloted in Coast Province from late 2005, DFF involved facilities receiving funds for recurrent expenditure directly into their bank accounts. This report presents an evaluation of the implementation and effects of DFF in health centres and dispensaries.
Methods: The findings in this report are based on data collected between October 2007 and March 2008, about 2 to 3 years after DFF implementation. A structured survey that included an interview with facility in-charges, records review, and outpatient exit interviews was conducted at a random sample of 15 facilities in each of the two purposively selected districts (Kwale and Tana River). In addition, focus group discussions with health facility committee (HFC) members and key informant interviews with in-charges and DHMTs were conducted in a subset of 6 facilities in each district.
Results: The study found that DFF accounted for an average of 56% of the facilities‟ annual income, while user-fees revenue accounted for 34%. DFF funds were particularly important for dispensaries, accounting for 62% of facility income. Wages for casual staff, travel allowances and construction and maintenance accounted for the bulk of DFF expenditure.
DFF procedures were generally well-established: all facilities had opened bank accounts and funds had been transferred; HFCs were active in planning for and use of the funds; and accounting procedures were generally followed. A few initial problems were noted, especially in training of HFCs in one district, and, whilst these had mainly been resolved by the time of data collection, confusion persisted over some aspects of DFF operation, reflecting limited HFC training and a lack of DFF documentation at facility level.
DFF was perceived to have had a highly positive impact by a great majority of the respondents. Utilization of facilities was thought to have increased, especially through the expanded outreach programs, thus improving access to health services. Although this resulted in a heavy workload for staff, there were no complaints about this as the increased workload was offset by the improved working environment, namely the availability of supplies and a better infrastructure, and by the ability to hire more support staff. Health worker motivation was also improved through provision of allowances; and, as a result of these changes, it was felt that quality of care had improved.
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. Interviewees attributed non-adherence to lack of official communication of the policy and the need for more resources at the facility level The operations of HFCs were reported to have improved since the introduction of DFF; however, only a minority of people in the broader community had the information to participate actively in decision making and hold HFCs to account. Only 46% of exit interviewees had ever heard of a HFC, while community members had very little knowledge on DFF procedures, how decisions were made, how DFF funds could be used, and what user fees should be charged. Specially designed blackboards aimed at displaying utilization data and a limited amount of financial information were available in most facilities but were rarely filled in completely.
Conclusions: DFF is perceived to be a highly valuable intervention and the current system is generally working well. The Kenyan Government plans to scale up DFF nationwide under the Health Sector Services Fund and our findings indicate that this is warranted; however, scale up of DFF should include improved training and documentation; greater emphasis on community engagement; and insistence on user fee adherence as a prerequisite for receipt of funds.
CREHS research report, April 2009, 28 pp.