Characteristics of Health Facility Committees in Kenya

1. 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. 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) BACKGROUND

3. What is HSSF?

4. 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 HEALTH SECTOR SERVICES FUND

5. With HSSF Without HSSF Financial Management

6. Broad Objective Collect and present nationally representative data on HFCs in Kenya in advance of the introduction of HSSF nationally Specific Objectives Document HFC characteristics and operations Assess patient awareness of their activities Describe roles and benefits of HFC members Explore HFC members motivation and job satisfaction STUDY OBJECTIVES

7. 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 STUDY DESIGN

8. DATA COLLECTION

9. 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 DATA COLLECTION

10. 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 DATA ANALYSIS

11. SUMMARY OF DATA COLLECTED

12. FINDINGS

13. 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%) HFC MEMBERSHIP AND SELECTION

14. 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 HFC MEMBERS’ CHARACTERISTICS

15. 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 HFC MEMBER TRAINING

16. Patient Awareness of HFCs

18. 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%) PERCEPTIONS OF HFC ROLES (CONT.)

19. 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 HFC MEETINGS AND ALLOWANCES (IN-CHARGE RESPONSES)

20. Benefits of Being a HFC Member

21. RELATIONSHIPS

22. > 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” RELATIONSHIP BETWEEN HFC MEMBERS AND THE IN-CHARGE: POSITIVE

23. 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” RELATIONSHIP BETWEEN HFC MEMBERS AND THE IN-CHARGE: CONCERNS

25. Conclusion

26. Supportive supervision was not as frequent HFC were not content with their allowances Concern of some tension between in-charges and HFC members Training • 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 SUMMARY Significant Challenges Positive Findings

27. 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 SUGGESTIONS FOR FOLLOW-UP

28. BETTER HEALTH BETTER DAYS