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 = 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 priority-setting 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.
Highlights
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)
This paper focuses on priority-setting practices in public hospitals in Kenya
Observations and discussions with hospital managers and staff identified the existence of a management structure which was highly hierarchical (Figure 2)
Summary
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 imperative (Martin et al 2003). Priority-setting research has mainly focused on macro (national) and micro (patient) level processes and rarely on the meso (regional and/ or organizational) level, hospitals (Martin et al 2003). There is a dearth of literature on hospital level priority-setting practices in LMICs. There is 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)
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