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Financial and non-financial information flows in the Kenya health sector: a pathway to health system accountability

Report – Financial and non-financial information flows in the Kenya health sector: a pathway to health system accountability - 853 KB

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Report – Analysis of flow and integration of financial and non-financial data in the education sector in Kenya - 3 MB

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Report – Health sector landscaping - 506 KB

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Executive Summary

Background

Strong health systems rely on robust data and evidence – financial and non-financial -, to design effective policies and interventions and to enhance accountability. Kenya has made significant efforts in streamlining and documenting resource flows in the health system. However, gaps remain with regard to the upward flow of financial and non-financial information, the integration of both types of data for decision-making, and how the integration supports health system accountability. The current information flow and accountability process primarily captures financial information. There is little to no integration with non-financial health information (activities, service outputs, and outcomes), thereby limiting rather than enhancing accountability.

In response to these gaps and challenges, IDinsight, in partnership with the Gates Foundation, mapped Kenya’s health system’s financial and non-financial information flows and explored the pathways to accountability in the data flow process. This report presents the findings of that exercise, undertaken between September 2023 and June 2024. As a separate but interlinked piece, we collaborated with Expertise Global, a public finance management consulting firm based in Nairobi, Kenya, to conduct a sector comparator study with the education sector. We present the comparative analysis in this report, highlighting the practices from education that could apply to the health sector.

Study Approach

We reviewed reports, publications, and datasets from databases and systems pertinent to Public Financial Management (PFM) and accountability within Kenya’s health sector, including the Kenya Health Information System (KHIS). We purposively sampled key stakeholders with visibility on the data flow process for interviews. We then analyzed and coded the responses by key themes, then validated the findings with sector experts and stakeholders.

Key Findings

The key findings from this landscaping exercise are as follows:

  • Overall, the integration of financial and non-financial health data is limited; when it happens, it is ad hoc. This is partly due to the lack of a definitive framework to guide the integration of financial and non-financial health data. As a result, it is difficult to ascertain if the allocations within the health sector budget (determined mainly by planning ceilings) and made on a line-item basis are effectively allocated to priority health programs.
  • The Kenya Health Information System (KHIS) is the central platform for aggregating and reporting health non-financial data in Kenya in a coordinated hierarchy from the community, facility, sub-county, and county levels to the Ministry of Health. Health Records Information Officers (HRIOs) at the facility and sub-county levels manage and report this data. While local facilities diligently collect health data, they often fail to utilize it effectively for performance review, strategic planning, and monitoring. There is also limited evidence on how this data is shared with Public Financial Management and accountability stakeholders, resulting in poor tracking of health outcomes against budgets and weakened oversight of health funds, increasing the risk of fund diversion.
  • The Integrated Financial Management Information System (IFMIS) is the main system for budgeting and financial reporting for all sectors. However, KHIS and IFMIS are not interoperable, hindering the integration of financial and non-financial data. This lack of interoperability makes it challenging to access and analyze both sets of information simultaneously, hindering informed decision-making.
  • Accountability is not solely the responsibility of one stakeholder; it involves a multifaceted participation of various actors, e.g. ( the County Assembly, the Office of the Controller of Budget (OCOB), the Office of the Auditor General (OAG), and Parliament, etc). This complexity obscures who is accountable to whom and for what and presents ample opportunities to shift blame between stakeholders. At its worst, this leads to growing governance problems that limit the ability of health sector managers to comply with multiple accountability demands and thus act effectively.
  • Although Kenya’s health and education sectors have relatively similar accountability frameworks, the education sector has a better-coordinated decentralized accountability structure. Compared to similar-level health facility management committees, School Boards of Management play a key role in planning and accountability, with a defined mandate to approve budgets and monitor school performance. The Directorate of School Audit (DSA) is responsible for auditing schools to promote accountability. The health sector lacks a similar institution to audit health facilities. This happens even though sub-county facilities exercise new decision-making powers, e.g., in the use of Facility Improvement Financing.

Conclusion and Implications

The findings from this landscaping exercise could inform improvements in critical decisions such as health budgeting, development of health policies, strategic planning, and enhancing health system accountability. Below, we highlight some areas for consideration and action:

  • Develop clear outcome-based guidelines and templates for capturing and reporting non- financial information. The government should emphasize the capture and utilization of non- financial information by all government institutions to support and justify financial expenditures. The National Treasury and the Ministry of Health MOH can develop a framework to guide the capture and reporting of non-financial health information and mandate an institution to coordinate this role. Housing this information in one place would enhance its utilization by actors responsible for holding the health sector accountable.
  • Institutionalize a framework for integrating financial and non-financial information at both the county and national levels. Integration would ensure relevant stakeholders have easy access to complete information to inform health resource allocation decisions, thereby improving health delivery. The MOH and the National Treasury could collaborate to develop the integration framework.
  • Establishing a formal institutionalized incentive structure for reporting non-financial data could improve the information flow process and ensure the timely availability of quality health data to inform health programming and accountability efforts.
  • Identify and support a well-coordinated platform for enhancing accountability at the national and county levels. Numerous actors are mandated to ensure accountability for health finances and performance at the national and county levels. Proper coordination of these actors and their roles is key to enhancing their effectiveness. Strengthening joint working groups between the finance and health teams, as well as partnerships between accountability duty-bearers and right-holders, could enhance the utilization of health resources, resulting in improved health outcomes.
  • Enhance financial and health information systems interoperability. The National Treasury and MOH should consider interoperability between KHIS and IFMIS to allow the systems to exchange information, easing the process of integrating financial and non-financial information.

Read the full report here.

Read our report on a sector comparator study with the education sector in collaboration with Expertise Global.

Read the health sector landscaping report here.