Essay Grade

Health Policy and Planning, 32, 2017, 329–337
doi: 10.1093/heapol/czw132
Advance Access Publication Date: 26 September 2016
Original Article
Setting healthcare priorities: a description and
evaluation of the budgeting and planning
process in county hospitals in Kenya
1
KEMRI Centre for Geographic Medicine Research – Coast, and Wellcome Trust Research Programme, Nairobi,
Kenya, 2Health Economics Unit, University of Cape Town, Cape Town South Africa, 3Centre for Tropical Medicine,
University of Oxford, Oxford, UK and 4Nuffield Department of Medicine, University of Oxford, Oxford, UK
*Corresponding author. KEMRI Centre for Geographic Medicine Research – Coast, and Wellcome Trust Research
Programme, P.O Box 43,640-00200, Nairobi, Kenya. E-mail: edwinebarasa@gmail.com
Accepted on 1 September 2016
Abstract
This paper describes and evaluates the budgeting and planning processes in public hospitals in
Kenya. We used a qualitative case study approach to examine these processes in two hospitals in
Kenya. We collected data by in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n ¼ 72), a review of documents, and
non-participant observations within the hospitals over a 7 month period. We applied an evaluative
framework that considers both consequentialist and proceduralist conditions as important to the
quality of priority-setting processes. The budgeting and planning process in the case study hospitals was characterized by lack of alignment, inadequate role clarity and the use of informal
priority-setting criteria. With regard to consequentialist conditions, the hospitals incorporated
economic criteria by considering the affordability of alternatives, but rarely considered the equity
of allocative decisions. In the first hospital, stakeholders were aware of – and somewhat satisfied
with – the budgeting and planning process, while in the second hospital they were not. Decision
making in both hospitals did not result in reallocation of resources. With regard to proceduralist
conditions, the budgeting and planning process in the first hospital was more inclusive and transparent, with the stakeholders more empowered compared to the second hospital. In both hospitals,
decisions were not based on evidence, implementation of decisions was poor and the community
was not included. There were no mechanisms for appeals or to ensure that the proceduralist conditions were met in both hospitals. Public hospitals in Kenya could improve their budgeting and
planning processes by harmonizing these processes, improving role clarity, using explicit prioritysetting criteria, and by incorporating both consequentialist (efficiency, equity, stakeholder satisfaction and understanding, shifted priorities, implementation of decisions), and proceduralist
(stakeholder engagement and empowerment, transparency, use of evidence, revisions, enforcement, and incorporating community values) conditions.
Key words: Budgeting and planning, deliberative democracy, hospitals, Kenya, priority-setting
C The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
V
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
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Edwine W. Barasa,1,2 Susan Cleary,2 Sassy Molyneux,1,3 and
Mike English1,4
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Key messages
•
•
•
Alignment of budgeting and planning practices, clarity of composition and roles of decision-making structures, and the
use of explicit and formal decision-making criteria could improve hospital level priority setting.
Hospital priority-setting practices could be improved by incorporating both efficiency and equity in decision making, and
yielding the following intermediate outcomes; stakeholder satisfaction and understanding, shifted priorities, implementa
tion of decisions.
Incorporating the following deliberative democratic principles; stakeholder engagement and empowerment, transpar
ency, use of evidence, revisions, enforcement, and incorporating community values, could also improve hospital level
priority-setting practices.
Hospitals consume a significant proportion (50–60%) of recurrent
national health budgets and are avenues for the delivery of key interventions (English et al. 2006). Understanding how these hospitals
set their priorities and the factors that influence their allocation of
resources is therefore imperative (Martin et al. 2003). However,
priority-setting research has mainly focused on macro (national) and
micro (patient) level processes and rarely on the meso (regional and/
or organizational) level, particularly hospitals (Martin et al. 2003).
Further, of the few studies examining the hospital level prioritysetting, the majority have been carried out in high income countries
(Barasa et al. 2015b). There is therefore a dearth of literature on
hospital level priority-setting practices in LMICs. This is consistent
with a general lack of evidence on priority setting frameworks and
their usefulness in LMICs (Wiseman et al. 2016).
This paper focuses on priority-setting practices in public hospitals in Kenya. In 2013, after a national election that ushered in a
new government, the country transitioned into a devolved system of
government with a central government and 47 semi-autonomous
units called counties (Government of Kenya 2010). Under this new
governance structure, the public healthcare delivery system is organized into four tiers, namely the community level, primary care level,
county referral hospitals and national referral hospitals (Ministry of
Health 2011). County referral hospitals, which are the focus of this
study, are first level referral hospitals in the county health systems.
Little is known about how the Kenyan health sector sets its priorities. At the macro level, it has been reported that priority setting is
ad hoc, rather than systematic, without explicit priority setting criteria (Ndavi et al. 2009). The sector is guided by a long term (15
years) national health policy which outlines health sector objectives,
and a short term (5 years) national health sector strategic plan which
articulates sector strategies aimed at achieving the policies laid out
in the national health policy. The health sector strategy outlines a
package of health services that are to be provided by the public sector, known as the Kenya essential package of health (KEPH)
(Ministry of Health 2005). Hospitals were therefore expected to
provide KEPH services, but had the authority to prioritize across
these services. On paper, the Ministry of Health employed a combination of top-down and bottom up planning to operationalize the
sector strategy (Ndavi et al. 2009). There are no official guidelines
in place on how the priority setting should be conducted at the
county hospital level. There is also no evidence/literature on how the
priority setting process is actually carried out within hospitals in
Kenya. We used a case study approach to examine priority-setting
practices in two of these hospitals. Specifically, this paper presents a
description and evaluation of the budgeting and planning process in
the case study hospitals. The budgeting and planning process was selected because it is, in theory, the major expression of identified and
selected hospital priority activities and services, with allocation of
available resources against those activities.
Methods
This study employed a qualitative case study design. A case study
has been defined by Yin (2003) as an empirical inquiry that investigates a contemporary phenomenon within its real life context. A
case study approach is considered suitable to inquiries into phenomena that are highly contextual and where the boundaries between
what is being studied and the context are blurred (Yin 2003). It has
been observed by several authors that priority setting practices in
hospitals are highly context dependent (Kapiriri and Martin 2010;
Martin and Singer 2003; Gibson et al. 2004). The case study approach is useful in building an understanding of the contextual influences on the phenomena of interest (Yin 2003; de Lange and
Flyvbjerg 2011). The case study approach is also considered appropriate for the study of complex social phenomena (Yin 2003; de
Lange and Flyvbjerg 2011). Priority setting is considered a complex
social process that confronts decision makers with significant theoretical, political, and practical obstacles (Hauck et al. 2004; Shayo
et al. 2013; Klein 1998). As observed by Flyvbjerg (2001), social
processes are complex and unlikely to yield universal truths or accurate predictions. An appropriate analysis should therefore aim to
develop concrete, context dependent knowledge (Flyvbjerg 2001).
These context specific insights could then be tested and examined in
other contexts in an iterative process of knowledge building.
Two county hospitals were purposely selected as cases for the
study. The two hospital cases were selected purposefully guided by
the following criteria: (1) First level referral hospitals that were designated as county hospitals; (2) hospitals with a high local resource
level and those with a low local resource level. This was based on an
assumption that priority-setting practices might be influenced by the
level of funding. In the financial year preceding data collection, one
of the case study hospitals had an annual budget of USD 528 862,
while the other had an annual budget of USD 384 472. These budgets remained fairly stable over the past 5 years. In line with case
study methodology, the selection of hospital cases aimed to ensure
depth in information, as opposed to aiming for representativeness of
all county hospitals in Kenya. To maintain confidentiality and minimize the potential identification and possible victimization of study
participants, the hospitals selected for the study will only be identified as Hospital A and B. Data were collected through a combination of in-depth interviews with hospital managers and frontline
workers, a review of relevant documents including hospital plans,
budgets, minutes of meetings, and non-participant observations for
a total period of 7 months in both hospitals. The selection of participants for interviews was purposive with the aim of selecting those
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Introduction
Health Policy and Planning, 2017, Vol. 32, No. 3
331
Table 1. Number of participants selected in each hospital under
each category
National-level key informants
Senior managers
Mid-level managers
Front-line practitioners
Hospital sub-total
Study total
5
Hospital A
Hospital B
6
22
7
35
6
19
8
32
72
Data analysis
Transcribed data were imported into NVIVO 10 for coding and
analyzed using a modified framework approach (Pope et al. 2000).
This approach was adopted because it is suited to providing findings
Ethical considerations
The authors received ethical approval from their organization.
Findings
Description of the budgeting and planning processes
Hospital decision-making structure. The case study hospitals did not
have an official organogram. However, observations and discussions
with hospital managers and staff identified the existence of a management structure which was highly hierarchical (Figure 2). At the
lowest level were frontline healthcare workers (such as pharmacists,
medical doctors, and nurses) and non-health staff (such as accountants and maintenance personnel), all of whom were answerable to
the heads of their respective departments. These heads of departments were middle level managers for clinical departments (e.g.
paediatrics, obstetrics and gynaecology), wards (e.g. adult male,
adult female and paediatrics), non-clinical departments (e.g. pharmacy and laboratory) and support departments (e.g. accounts and
maintenance) who were themselves answerable to the three senior
hospital managers namely the medical superintendent, the hospital
administrator and the hospital nursing officer in-charge. The medical superintendent was the chief executive of the hospital and was
responsible for the overall running of the hospital. The hospital
nursing officer in-charge was in charge of the nursing department
and hence all nursing wards in charges. The hospital administrative
officer was in charge of all the hospital non-clinical departments.
The case study hospitals had 3 management and decision-making
committees. First, there was a hospital management team (HMT),
comprised of all hospital departmental managers (middle level managers) and senior managers. Second, there was an executive expenditure committee (EEC), comprised of only the senior managers, and
third, there was the hospital management committee (HMC) which
was an oversight committee that drew its membership from the local
resident community. The hospital was represented in the HMC by
the medical superintendent, who was also its secretary, and the hospital administrative officer.
Budgeting and planning process. The budgeting and planning process was comprised of two distinct activities; quarterly budgeting
and the annual work planning (AWP) process. The development of
the hospital budget and the AWP were designed to be linked and
aligned. At the beginning of each government fiscal year (July 1),
hospitals were required to develop and submit AWPs to the central
Ministry of Health (MOH) for approval. Hospitals were then
required to develop quarterly budgets that outlined the allocation of
available resources to the priorities indicated in the AWPs. Hospital
AWPs were developed by the HMT and submitted to the regional
office for onward transmission to the central Ministry of Health
(MOH) for approval. While the range of services provided by hospitals was guided by KEPH, hospital managers had autonomy to allocate available resources across service areas (i.e. prioritize across
these services). The budgeting process should begin at the hospital
department level, where departmental managers develop a list of departmental needs and present these to the HMT. The HMT then deliberates on the departmental needs and develop budgets that
allocate available cash budgets across hospital departments. These
budgets should then be deliberated upon and finalized by the EEC
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who had an in-depth knowledge and experience of the budgeting
and planning process. This included senior managers, middle level
hospital managers, frontline practitioners and key informants within
the planning departments of the central Ministry of Health. In total,
72 participants were interviewed; 35 from Hospital A, 32 from
Hospital B and 5 from the central Ministry of Health (Table 1).
This study was broadly guided by the approach proposed by
Martin and Singer (2003) on improving priority-setting in healthcare organizations. This approach proposes that efforts to improve
priority-setting in healthcare organizations should entail (Martin
and Singer 2003): (1) critical description of priority-setting processes
using case study methods; (2) evaluation of priority-setting using an
ethical framework and (3) action research to improve prioritysetting based on the findings in the first two steps. While this paper
focuses on step one and two, it is part of a wider action learning
study to improve governance and accountability in the county health
systems in which the case study hospitals are located.
To evaluate the budgeting and planning process in the case hospitals we applied a published evaluative framework that was developed from a review of literature on priority-setting evaluation
(Barasa et al. 2015a). Our evaluative framework is based on the argument that both consequentialist and proceduralist conditions are
important for successful priority-setting (Barasa et al. 2015a). The
framework brings together these two perspectives by drawing on
ethical and deliberative democratic frameworks such as the wellknown ‘accountability for reasonableness’ framework (AFR)
(Daniels 2008), as well as consequentialist conditions of prioritysetting (Barasa et al. 2015a). This integrated evaluative framework
makes the following proposals (Figure 1) : First, given that prioritysetting is necessitated by the scarcity of resources, priority-setting
processes should incorporate efficiency considerations by seeking to
maximize outcomes within the constraint of available resources.
Second, the goal of maximizing desired outcomes should be tradedoff against equity. To achieve equity, the distribution of resources
should be determined by need rather than other factors such as ability to pay, favouritism or political consideration. Third, other intermediate outcomes of priority-setting processes are also important.
These include: (1) Stakeholder satisfaction; (2) Stakeholder understanding; (3) Shifted (reallocation of) resources and (4)
Implementation. Fourth, the following proceduralist conditions
should be incorporated in priority-setting practices: (1) stakeholder
involvement; (2) empowerment; (3) transparency; (4) revisions; (5)
use of evidence; (6) enforcement and (7) incorporation of community values.
and interpretations that are relevant to policy and pragmatic recommendations. The approach included an initial open coding step to
support the emergence of important themes, which might not have
been captured in the evaluative framework described above.
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Figure 2. Hospital Organogram
and subsequently presented to the HMC for review and approval.
Budgets approved by the HMC should then be submitted to the regional level and from there submitted to the MOH for approval.
Non-alignment of the budgeting and planning process. While the
budgeting and planning process was expected to be linked and
aligned, in practice, this was not the finding in both case study hospitals. The AWP was developed almost one quarter in the planning
year, while the budgets were developed on time at the beginning of
every quarter. This meant that the first budget of the year was often
developed without the existence and hence any reference to the
AWP. Subsequent budgets were also developed without reference to
the AWP. The result was that activities budgeted for in the quarterly
budgets were dissimilar to activities planned and budgeted for in the
AWP. As a result of this non-alignment, hospital managers placed
little importance to the AWP process. Very few managers knew
what was contained in the AWP, very few participated in the process, and hardly any cared about implementing the AWP.
People just fill the [AWP] template very fast but they don’t even
know what they are putting in the plans. If you ask people ‘okay
you did the AWP some three months ago do you remember what
you did?’ Most of the people don’t have an idea. They’ll tell you
‘we did it and it has already been sent to the province. We finished that business. Middle level manager, Hospital A
Decision-making criteria. Formal and informal criteria were used to
allocate budgets. Formal criteria are objective criteria that were used
explicitly by hospital decision makers to determine how the hospital
budget was allocated across departments and/or services. Informal
criteria refer to subjective considerations, which were often implicitly employed, that influenced budget allocation decisions in hospitals. To get an idea of the prominence of criteria used in the case
study hospitals, we developed a word cloud by identifying decisionmaking criteria mentioned in interview transcripts and the number
of times they were mentioned (Figure 3). The criteria identified will
be discussed next.
Formal criteria. In both case study hospitals, the dominant criterion
used to allocate budgets to hospital departments and services was
the revenue generating potential of the departments. Departments or
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Figure 1. Framework for evaluation for priority setting
Health Policy and Planning, 2017, Vol. 32, No. 3
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Figure 3. Word cloud of priority-setting criteria in the case study hospitals
The hospital generates very little money which means priorities
have to change. . .So first we want to make money, we allocate
where we can make money. . . Middle level manager, Hospital B
Historical budgeting also featured prominently among the criteria used by managers to allocate budgets across departments in both
hospitals. Departments often received the same budgetary allocation
or increments to previous year’s budgets. The lack of technical competence in budgeting and planning, and lack of priority-setting
guidelines, together with resource scarcity also contributed to the
use of historical budgeting (Barasa et al. in press). Managers also
considered the extent of necessity of a service in making budgetary
allocation decisions. Services were considered essential if the hospital could not run without them. The perceived medical need in the
hospital’s catchment area was also a determinant of hospital allocations. The need was however based on the volume of patients seeking different services at the hospital rather than any formally
assessed need in the community. Other formal criteria used included
international and national priorities such as the Millennium
Development Goals, the feasibility of implementing the service, and
affordability of proposed services.
Informal criteria. In contrast to the formal criteria identified above,
managers in Hospital A felt that allocative decisions were influenced
by informal criteria such as the lobbying and bargaining ability of
departmental managers.
You see you can have a head of department who is not very vocal
and does not articulate your needs as well as they should. . .some
departments. . .they seem to always get more than others. . .it all
depends on how eloquent and convincing the head of department
presents his proposals. Middle level manager, Hospital A
Resource allocation was also dependent on interpersonal relationships and mutual benefit between the middle-level managers and
the senior managers.
Allocations depend on your relationship with the hospital administrators. . .we mean in life sometimes things work because of relationships right? You are a friend of mine and we get along well
so we will allocate something to you. Middle level manager,
Hospital A
Middle level managers at Hospital A also felt that allocations
favoured the senior managers who were part of the EEC. The use of
these informal criteria was made possible in Hospital A because
there was little deliberative space in the budgeting process. Given
that actual allocation decisions were made by a small group of senior managers (EEC), this provided an opportunity for the EEC
managers to leverage on their unique position to favour their departments and the departments of those with whom they enjoyed good
relationships.
The situation was different in Hospital B where the middle level
managers, through the HMT, were empowered to make allocation
decisions. While managers in this hospital also felt that the bargaining and lobbying ability of managers had an influence, the general
feeling was that favouritism did not influence decisions. The result
was that while in Hospital A managers generally felt that the allocation decisions were unfair, in Hospital B the feeling was that allocations were relatively fair.
We don’t get all that we need but we can say that the budgeting is
fair. The medical superintendent ensures there is equity. At least
each department gets something small. Middle level manager,
Hospital B
Evaluating priority-setting
In this section, we use the framework that we previously developed
(Barasa et al. 2015a) to evaluate the budgeting and planning process
in the case study hospitals. We first present our findings on the use
of consequentialist principles followed by the adherence to proceduralist conditions.
The use of consequentialist principles.
Efficiency and equity. Hospital managers were unfamiliar with mechanisms such as cost-effectiveness analysis (CEA) and program budgeting and marginal analysis (PBMA). When the basics and rationales
of these methods were explained to them, they responded that although the methods were potentially useful in decision-making, they
lacked the technical skills and data required. However, in both hospitals, budgeting and planning decisions considered the affordability
of competing alternatives. This could be argued to be an attempt to
incorporate efficiency, given the capacity and data constraints that
the hospitals faced. By taking into account the costs and affordability of competing priorities, managers were recognizing budget limitations and the need to make decisions such that the hospital could
get the most out of available resources.
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services that generated more revenue from user fee collections were
prioritized over departments that generated less revenue and subsequently received a larger share of the hospital budget. The reason
given for using the revenue generating potential of departments is
that the hospitals experienced a severe scarcity of resources and
relied on user fee collection to finance their daily operations (Barasa
et al. 2016). To make sure that the hospital continued to run, resources had to be allocated in a manner that assured further generation of revenues:
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In both case study hospitals, the dominance of revenue maximization as a priority-setting criterion meant that departments (and
hence patient groups such as children under 5 years) that did not
generate user fee revenues were systematically underfunded compared to departments that generated user fee revenues. This practice
meant that budget allocations were inequitable. Further, the reported favouritism in resource allocation given to departments
headed by senior managers and those whose managers enjoyed good
relationships with senior management could also be considered as
sources of inequity.
Stakeholder understanding (awareness). The level of understanding
varied across stakeholders and was related to their level of engagement. For example, while in Hospital A the middle level managers
had a low level of understanding of the budgeting process given that
they were excluded from it, in Hospital B, the middle level managers
reported adequate understanding of the process because they were
involved in it.
Shifted priorities (reallocation of resources). In both case study hospitals, budgeting and planning processes did not result in shifted resources. This was because budgeting and planning in these hospitals
was significantly guided by historical allocations. The budgeting and
planning process was therefore not responsive to the changing dynamics of resource needs.
Implementation of decisions. The implementation of budgeting and
planning decisions was fairly similar between the case study hospitals. The planning processes in both hospitals were considered to
be mainly an activity on paper that was hardly implemented in practice. A number of reasons, which we have reported elsewhere, led to
the lack of implementation of decisions including the lack of resources, reduced motivation due to reduced autonomy of hospital
managers over planning decisions, a culture where hospital staff
lacked a sense of duty and commitment to their roles and responsibilities, and the lack of strong internal accountability mechanisms
(Barasa et al. in press).
Compliance with proceduralist conditions.
Stakeholder engagement. The degree of stakeholder engagement varied across the case study hospitals, with the budgeting and planning
process being more inclusive in Hospital B, compared to Hospital A.
While hospital budgets were discussed by the HMT in Hospital A,
final budgeting decisions were made by the EEC. Given that the
EEC was a smaller committee that comprised of senior managers
only, middle level managers felt excluded from the budgeting process. In Hospital B however, as mentioned above, final budgeting
decisions were made by the HMT which was a larger committee
that comprised of both senior and middle level managers. The HMT
meetings also allowed for greater deliberation and discussion.
We present budgets and people are asked to say why they need
the money. At least we get to understand why a department’s
budget is like this or like that. People also see why for example
they are going to get less than what they asked for. . ..because we
also discuss what [resources] is available and how much departments can get. Middle level manager, Hospital B
In both hospitals, however, frontline clinicians rarely participated in budgeting and planning processes. While it was reported
that they were not invited in Hospital A, frontline clinicians did not
participate in Hospital B despite being invited. As we have discussed
elsewhere, it appeared that the main reason for non-participation of
clinicians was professional identity (Barasa et al. in press).
Clinicians in both hospitals did not seem to think that managerial
responsibilities such as budgeting and planning were part of their
roles as professionals. They identified themselves more with their
clinical roles and considered time spent doing managerial duties as
‘wasted time’ (Barasa, et al. in press). The shortage of clinical staff
also contributed to the non-participation of clinicians in budgeting
and planning meetings (Barasa et al. in press). As will be discussed
below, community members were involved only very peripherally in
the budgeting and planning processes in both case study hospitals.
Stakeholder empowerment. The level of empowerment of different
stakeholders varied between the case study hospitals. In Hospital A,
middle level managers appeared to have a low level of empowerment to participate in budgeting and planning activities compared
to Hospital B.
Decision making is not democratic. I think it’s dictatorial because
at the end of the day whatever decisions are made at HMT meetings, we’re still going to hear of another meeting that was held with
another committee and basically whatever we had come up with
will not even be considered. Middle level manager, Hospital A
Further, actors who were not engaged in the priority-setting process (clinicians and the community) were clearly not empowered to
contribute to decision making either.
Transparency. The extent to which the budgeting and planning process was transparent varied between the case study hospitals.
Generally, Hospital B exhibited more transparency. In Hospital A,
there was no mechanism in place for disseminating budgeting and
planning decisions, and once the final budgets and AWPs had been
prepared, they were not shared with the hospital managers. Only selected senior managers had access to these documents, and for both
processes, the reasons for decisions were not communicated to the
managers. Front line practitioners also reported that they were in
the dark as far as budgeting and planning decisions in the hospital
were concerned. In Hospital B, a more inclusive budgeting and planning process meant that managers were generally more aware of the
budgeting and planning decisions and the rationales behind them.
They therefore reported that the process was transparent.
Nevertheless, as with Hospital A, they reported that final budgets
and work plans were not made available to them unless they individually sought them out.
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Stakeholder satisfaction. The level of satisfaction with the budgeting
and planning process varied between hospitals. In Hospital A, stakeholders (senior and middle level managers, and frontline practitioners) were not satisfied with the budgeting and planning process
because the process was generally not inclusive, leaving most stakeholders disgruntled. Further, the scarcity of resources meant that
hospital managers were not satisfied with the resources that were
allocated to them. The use of revenue generation criterion also left
the managers whose departments generated little revenue disgruntled. In Hospital B, the stakeholders repor