Strengthening Health Outcomes through Facility Improvement Funds (FIF) – A Case Study of Makueni County

The government of Kenya through the ministry of health is committed to strengthening primary healthcare systems as precursors to the attainment of Universal Health Coverage (UHC). Putting in place resilient mechanisms to enhance the quality of care offered to the communities helps to improve the health and the well-being of the people, especially the last-mile communities. Through the facility improvement funds and the Makueni Social Cover, the county has been able to enhance its health service delivery with greater impacts on its people who can readily access quality and affordable healthcare.

In 2014 and 2020, the ministry of health advised the 47 counties to develop facility improvement fund (FIF) Acts through their respective county assemblies. This was to ensure that public health facilities are empowered to, raise, retain and utilize their own revenues. A few counties including Makueni hid to the call whilst others still depend on the county exchequer to finance the operations and maintenance of county health facilities which is not effective, thus impeding the quality of care offered to the communities.

Facility improvement fund (FIF) is important to the health sector because

• It is a reliable source of funding to County Health Facilities (drawn from Cash, Insurance Schemes and Grants), it is recognised as appropriation in aid.
• It is an opportunity to further decentralise decision-making in the health sector (both financial and managerial autonomy); this ensures the optimization of the available resources.
• It is an opportunity to bring the discipline of revenue collection, improvement of service offering and delivery of quality service
• It entrenches the culture of performance in the health sector. strengthens teamwork and results-focus culture at the health facility.

Sources of facility improvement fund (FIF) at the county level

• User fees for public hospitals (paid in cash) / cost sharing amounts)
• Grants from National/County Government/ Development partners
• Insurance schemes (NHIF Schemes and other schemes)
• Linda-mama antenatal clinics (ANC – 4 visits, Delivery and Post-natal)
• NHIF super-cover (In-patients, out-patient and Edu Afya)
• Universal Health Coverage (UHC)

The county adopted the following strategies to strengthen the quality of health service delivery at the county level

• All revenues collected are 100% banked in the facility bank account.
• The facility has gone cashless to avoid instances of handling solid cash, reducing instances of misappropriation.
• The use of the Funsoft software (system) to collect county hospital revenue.

To enhance efficiency and effectiveness in the performance of health facilities with the support of the facility improvement funds the Hospital Board/Facility Management Committee, through its various sub-committees performs the following;

• Meet every quarter to prepare budgets,
• Health Management Team-Provision of departmental budgets
• Executive Expenditure sub-Committee – Scale down budgets as per available funds
• The finance sub-committee scrutinizes the presented budgets further in relation to the previous budgets and allocations.
• Primary and quality sub-committee-supervise quality of care.
• Health Management Team-main committee mandated to approve the budget for forwarding to the CO-health services

At the county HQ level, a committee called County Health-Authority to Incur Expenditure Committee (CHAIEC) is formed, which is mandated to invite hospital managers, for example, the Medical Superintendent, Health Administration Officer, Accountants and Nursing officers in charge for an AIE defense meeting. It comprised 9 members. The committee together with managers keenly discusses, amends and agrees on the budget proposal. After the intense discussion, the chairperson forwards the budgets proposal for approval to CO-health services, which upon approval, the AIE is issued with a copy, signed by both CO-health and CO-finance

Key lessons learned during the Makueni inter-facility FIF learning exchange programme include the following:

• When health facilities are given financial autonomy, they are able to complement other essential health services and commodities procured by the county (KEMSA /MEDS) through local suppliers and therefore avoid commodity shortages.
• The funds retained at the facility level are used to employ additional staff on locum both, support and technical staff. Some of the funds are used for assets and infrastructure improvement, for example, the contraction of wards.
• With increased reimbursement by NHIF to the facility through Edu Afya and Linda Mama covers, the facility is able to go the extra mile and lobby for additional resources – by registering more patients to the covers.
• County Health AIE Committee plays a critical role in assisting the COH to review and approve the budget for the facility to utilise funds.

It is evident that when funds are well managed and accounted for, there is a seamless trajectory that leads to effectiveness and efficiency in the way health units deliver their services to the people. The ministry of health should continue to work collaboratively with health facilities at the county level, to enhance the availability and access to quality and affordable health care to the people at the community level.

Author – Noah Wekesa W. CA, Digital Lead, Amref Health Africa