Maximum return on PHC investments through provider-community collaboration

“Our catchment population is 4084 and our biggest challenge is human resources. Only 2 nurses are covering this huge catchment population. According to Universal Health Care standards we are supposed to have 8 nurses. This is a big human resource gap.” - Razia, health worker at Ndegele, PHC facility in Bungoma county Kenya

For 10 years now, responsibility for governing healthcare has been devolved from the national to county level governments. If well harnessed, devolved decision making of health to lower levels of government provides a significant opportunity to effectively use available resources and strengthen primary health care (PHC) facilities.

Two anticipated successes of devolved governance of health services in Kenya are increased investment in primary health services and contextualized health interventions that engage grassroot actors. The 47 semi-autonomous counties are responsible for the identification and design of interventions that respond to local health needs. Even though more funds have been allocated to primary health facilities, this has often not translated into increased quality of care for the communities they serve. Mechanisms for the communities to give feedback on how primary health care resources are utilized are either inadequate, poorly understood, or not effectively implemented.

“Usually when funds are deposited, we have to convene the community facility board to discuss and make approvals on how they will be utilized. The board members are far, and it can take a long time to convene a meeting. This might not respond to some urgent needs in the facility,” - Razia, health worker at Ndegele, PHC facility in Bungoma county Kenya

Asymmetric information is a barrier to accountability for PHC
Communities are not equipped to measure the performance of their primary healthcare facilities because of many factors. For example, the information on resources that their health facility is supposed to receive is complex and often not available to them. They are often not familiar with the jargon used by experts to measure access, quality, and responsiveness of health services to target populations. Communities often do not have access to information about the size or sources of funds allocated to them, or how health resources are spent. This makes them unable to hold political leadership and providers to account.

This information gap also limits the extent to which health facilities can work with communities to advocate for more resources from the government. Therefore, decisions on how funds are spent are not informed by the needs of local communities, reducing efficiency. With communities having a weak voice in mechanisms that manage resources for health services at their local facility, PHC priorities often do not respond sufficiently to their needs. As a health worker, Razia knows where use of resources can be most effective to positively change health outcomes:

“The facility community board should consider how to use the funds and support the work of CHVs. I would love if the facility would give them refunds during referrals when they identify women and other patients from the community and support them to reach the facility.”

Kenya is making great policy strides in financing for PHC
Kenya is taking steps to amalgamate financing pools through one social health insurance scheme – the National Health Insurance Fund (NHIF). The fund has become even more important given major national government and international donors are reducing their funding for primary health care.

“In the 2021/2022 financial year, the DANIDA funds have really delayed, the NHIF payments from Linda Mama has also delayed and lack of these funds really affect the operations of the facility.” Siyo, PHC facility in-charge, Ekitale in Bungoma county, Kenya.

Siyo paints a picture of the funding bottlenecks that exist since Kenya’s devolved governance.

“The challenges we are facing right now is drugs. I have been here for the last 4 months, and we have not been having supplies. We have to ask clients to buy drugs from outside. The facility doesn’t have funds.”  - Juma, Clinical officer at Mayanja PHC facility in Bungoma county, Kenya

Juma’s insight underscores the need for Kenya to improve the way in which PHCs are resourced.  Fortunately, there are progressive policies that would positively impact service delivery at all levels of the health system.

Moving forward, PHC will largely be funded from three major sources. Health facilities will receive direct credit to primary health facility bank accounts from various sources, including the NHIF, donors, county allocation, and user fees. The counties will also be part of decisions on central procurements, including human resources for health (HRH), health commodities and technologies, and centrally procured operations and maintenance. These changes provide an opportunity for a less fragmented financing landscape, enabling more transparency and therefore more accountable funding of PHC.

Communities can accelerate the journey towards UHC
If provided with the right support, health facility committees, that exist of voluntary community representatives, can hold providers to account on how funds at their local health facility are spent. As they know their communities best, they can advise providers on how to spend funds in a way that meets their needs.

Connecting community members with grassroot advocates, media and civil society organizations (CSOs) will ensure that their needs are brought to the attention of decision makers. Juma* passionately explains how the facility, its health workers, and local civil society can work with communities to unlock new sources of revenue to support facility operations.

“Through public participation, we are working with the community to ask for more resources to complete a maternity unity. Our local civil society is working closely with the community and leaders. Having a maternity ward will make this facility access more funds from the Linda Mama programme.” - Juma, Clinical officer at Mayanja PHC facility in Bungoma county, Kenya

PHC providers are struggling to convince women to immunize their children and give birth in their facilities. Community engagement is essential to make providers understand the perspective of those who use services at their facility. This can help providers to adapt and increase access and quality of PHC provision, to bridge the gap towards UHC.

To accelerate the provision of primary healthcare as a human right for all, we are asking governments around the world to work with local health actors to design mechanisms for engaging communities in decisions on how primary health care funds are spent.  

This opinion piece is part of a blog series by the Allies Improving PHC for the 75th World Health Assembly that aims to highlight Primary Health Care as the foundation for achieving universal health coverage, health security and healthier populations globally. Pieces will be posted throughout the week of the 75th World Health Assembly, read more here.