Dr. Rahab Mbau Dr. Edwine Barasa

1. How can we make healthcare purchasing in Kenya more strategic? KENYA PAEDIATIC ASSOCIATION ANNUAL SCIENTIFIC CONFERENCE, 10th April 2019, SAROVA WHITESANDS HOTEL. Dr. Rahab Mbau Dr. Edwine Barasa

3. What is healthcare purchasing? The allocation of funds to healthcare providers for the provision of healthcare services for identified groups of people. Three key decisions in purchasing: Who to buy from? Choosing service providers based on equity, efficiency and quality of health service delivery What to buy? -Identifying services to be purchased (Benefit Package) How to buy? Determining how services will be purchased including contractual arrangements and provider payment mechanisms

4. Types of healthcare purchasing arrangements Passive purchasing- Based on predetermined budgets or simply paying bills when presented without consideration of equity, efficiency of quality of service delivery. Strategic purchasing-seeks to optimize health system goals of equity, efficiency, and quality of care towards universal health coverage by linking payments to information on performance and health needs of the population

5. Purchasing relationships and key strategic purchasing actions Citizens Government Actively identify the health needs, preferences and values of the population for the creation of an affordable benefit package Regular public reporting on their use of funds, services purchased and other related activities Stewardship role – Establish clear policy and regulatory frameworks and, governance and accountability mechanisms. Fill service delivery infrastructure gaps Provide feedback and complaints to the purchaser Purchasers Choose providers, establish contractual mechanisms and payment systems, provide guidance on service provision, establish clear systems for monitoring performance and quality improvement Deliver an appropriate mix of healthcare services of acceptable quality and price; submit information on services provided Providers

6. Overview of purchasers, payment methods and providers in Kenya

7. Key challenges towards strategic purchasing in Kenya 1 Weak stewardship by the government Lack of specific laws and regulatory frameworks on:-Minimum benefit package; Provider selection and contracting, Provider payments 2 Passive provider payment methods • Not linked to performance, quality of care • E.g Line-item budgets, • Inadequate and delayed “We have planned for the financial year. Half the year is gone; we have not received any funding.” Middle‐level manager, County D

8. 3 Inadequate resource for service delivery particularly in public hospitals Inadequate drug supplies Inadequate medical equipment Inadequate health facilities by population Inadequate human resource for health • “There is no facility that offers the comprehensive range of services as outlined in the KEPH due to financial and human resource constraints” Senior-level manager, County C

9. 4 Weak implementation of quality assurance and accountability mechanisms Inadequate surveillance & quality monitoring (including support supervision) “Surveillance should be done at least twice a week but we face challenges. There are many contracted health facilities and fewer quality officers so it is not easy for us to reach all of them." NHIF branch official, County B Lack of clear frameworks and reporting structures for monitoring and evaluating provider performance “We had a very nice system where before our role was actually to inspect the facilities and fill the appropriate forms and send them to relevant bodies. Now that role has been put by the constitution to the counties yet there are no proper mechanisms.” Senior‐level manager, County G Inadequate availability and use of treatment guidelines and essential drug lists .

10. 5 Inadequate beneficiary voice and exit mechanisms Absent or inadequate voice mechanisms 1. Limited and/ or poorly inclusive public facilitation forums “We have not seen a single day that we have done this public participation on health” Senior manager, county G “The citizens are rarely consulted on what projects the county government is funding therefore their priorities are not taken into account.” Civil society organisation, County I Limited exit mechanisms Exit is especially limited for formal sector employees for whom the NHIF is mandatory or who access private health insurance as an employment benefit. 

11. Policy recommendations towards strategic purchasing Improve infrastructure for health service delivery • Explicit priority setting • Explore intercounty collaboration- esp. for expensive medical equipment and highly specialized personnel Strengthen stewardship of government 1 • Through explicit policy regulations on purchasing 2 Strengthen implementation of quality assurance mechanism 3 • Introduce clear frameworks and reporting structures for monitoring provider performance • Introduce contractual elements with clear performance standards Strengthen beneficiary voice and, complaints and feedback mechanisms 4 • Include this as part of performance monitoring and evaluation • Improve public’s awareness of public participation forums

12. Strengthen provider payment mechanisms • Informed by evidence and involve stakeholders • Timely, adequate and Linked to quality of care 5 Conclusion Purchasing of health care services in Kenya is not strategic Purchasers in Kenya should use their financial and decision-making power to promote improved quality, equity and efficiency in the delivery of health services towards Universal Health Coverage

13. Acknowledgements