The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya
The financing of public health facilities influences their performance. A key feature that defines health facility financing is the degree of financial autonomy. Understanding the factors that influence public health facility financial autonomy is pertinent to developing strategies to addressing cha...
| Main Authors: | , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
BMJ Publishing Group
2022-11-01
|
| Series: | BMJ Global Health |
| Online Access: | https://gh.bmj.com/content/7/11/e010260.full |
| _version_ | 1811307809082441728 |
|---|---|
| author | Edwine Barasa Benjamin Tsofa Anita Musiega Angela Kairu Stacey Orangi Lizah Nyawira |
| author_facet | Edwine Barasa Benjamin Tsofa Anita Musiega Angela Kairu Stacey Orangi Lizah Nyawira |
| author_sort | Edwine Barasa |
| collection | DOAJ |
| description | The financing of public health facilities influences their performance. A key feature that defines health facility financing is the degree of financial autonomy. Understanding the factors that influence public health facility financial autonomy is pertinent to developing strategies to addressing challenges that arise from constrained autonomy. In this paper, we apply a complexity lens to draw on a body of research that we have conducted in Kenya over the past decade, from the onset of devolution reforms, to unpack the determinants of public health facility financial autonomy in a context of decentralisation and provide suggestions for pertinent considerations when designing interventions to address financial autonomy challenges. We find that the factors that affect public health facility autonomy are not only structural, but also procedural, and political and interact in complex ways. These factors include; the public finance management (PFM) laws, sense-making by actors in the health system, political interests in control over resources, subnational level PFM capacity, PFM implementation bottlenecks and broader operational autonomy. Drawing from this analysis, we recommend that efforts at resolving public health facility financial autonomy include: PFM capacity development for subnational levels of government in decentralised settings, the use of a political lens that recognises interests and seeks to align incentives in engagement and solution finding for health facility financial autonomy, the audit of PFM processes to establish and resolve implementation bottlenecks that impinge on public health facility autonomy, and the resolution of operational autonomy to as a facilitator of financial autonomy. |
| first_indexed | 2024-04-13T09:10:55Z |
| format | Article |
| id | doaj.art-2ea78e89216f4d3c91c1e7b7622d2261 |
| institution | Directory Open Access Journal |
| issn | 2059-7908 |
| language | English |
| last_indexed | 2024-04-13T09:10:55Z |
| publishDate | 2022-11-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | BMJ Global Health |
| spelling | doaj.art-2ea78e89216f4d3c91c1e7b7622d22612022-12-22T02:52:53ZengBMJ Publishing GroupBMJ Global Health2059-79082022-11-0171110.1136/bmjgh-2022-010260The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in KenyaEdwine Barasa0Benjamin Tsofa1Anita Musiega2Angela Kairu3Stacey Orangi4Lizah Nyawira5Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, KenyaHealth Policy and Systems Research, KEMR-Wellcomoe Trust Research Programme, Kilifi, KenyaHealth Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, KenyaHealth Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, KenyaHealth Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, KenyaHealth Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, KenyaThe financing of public health facilities influences their performance. A key feature that defines health facility financing is the degree of financial autonomy. Understanding the factors that influence public health facility financial autonomy is pertinent to developing strategies to addressing challenges that arise from constrained autonomy. In this paper, we apply a complexity lens to draw on a body of research that we have conducted in Kenya over the past decade, from the onset of devolution reforms, to unpack the determinants of public health facility financial autonomy in a context of decentralisation and provide suggestions for pertinent considerations when designing interventions to address financial autonomy challenges. We find that the factors that affect public health facility autonomy are not only structural, but also procedural, and political and interact in complex ways. These factors include; the public finance management (PFM) laws, sense-making by actors in the health system, political interests in control over resources, subnational level PFM capacity, PFM implementation bottlenecks and broader operational autonomy. Drawing from this analysis, we recommend that efforts at resolving public health facility financial autonomy include: PFM capacity development for subnational levels of government in decentralised settings, the use of a political lens that recognises interests and seeks to align incentives in engagement and solution finding for health facility financial autonomy, the audit of PFM processes to establish and resolve implementation bottlenecks that impinge on public health facility autonomy, and the resolution of operational autonomy to as a facilitator of financial autonomy.https://gh.bmj.com/content/7/11/e010260.full |
| spellingShingle | Edwine Barasa Benjamin Tsofa Anita Musiega Angela Kairu Stacey Orangi Lizah Nyawira The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya BMJ Global Health |
| title | The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya |
| title_full | The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya |
| title_fullStr | The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya |
| title_full_unstemmed | The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya |
| title_short | The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya |
| title_sort | autonomy of public health facilities in decentralised contexts insights from applying a complexity lens in kenya |
| url | https://gh.bmj.com/content/7/11/e010260.full |
| work_keys_str_mv | AT edwinebarasa theautonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT benjamintsofa theautonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT anitamusiega theautonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT angelakairu theautonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT staceyorangi theautonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT lizahnyawira theautonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT edwinebarasa autonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT benjamintsofa autonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT anitamusiega autonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT angelakairu autonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT staceyorangi autonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya AT lizahnyawira autonomyofpublichealthfacilitiesindecentralisedcontextsinsightsfromapplyingacomplexitylensinkenya |