Purchasing in the public health system in Kenya.

Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions. Health system functions may also influence the health system’s ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic.We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Purchasing arrangements: COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme’s benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources. Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

诸如COVID-19大流行这类对卫生系统的突发冲击，可能会破坏卫生系统的各项职能；而卫生系统的职能本身，也会影响其在应对COVID-19这类突发冲击时的服务供给能力。本研究聚焦肯尼亚地区，探讨了COVID-19疫情对卫生筹资职能的影响，以及特定卫生筹资安排在疫情期间如何作用于卫生系统的服务供给能力。
本研究采用质性研究范式，在肯尼亚经目的抽样选取的3个县开展横断面研究。数据采集采用深度访谈（n=56）与相关文件评审两种方式，访谈对象涵盖国家级卫生筹资利益相关方、县卫生部门管理人员、医疗机构管理人员以及COVID-19医护人员。本研究采用框架分析法对采集到的数据进行分析。
采购安排：COVID-19相关服务由肯尼亚政府提供部分补贴，但由于此类服务成本高昂，民众仍需承担自费支出。肯尼亚国家健康保险基金（National Health Insurance Fund, NHIF）对面向正规就业群体的升级版保障方案进行了调整，将COVID-19服务纳入其保障范围，但并未针对面向社会低收入群体的基础保障方案作出任何适配调整，这一做法可能对医疗公平性产生潜在影响。
公共财政管理（Public Finance Management, PFM）体系：国家级层面，公共财政管理流程具备一定适应性与灵活性，可缩短预算编制与采购流程的耗时；县级层面，公共财政管理体系具备部分灵活性，可实现部分资源的重新调配，但仍保留了集中化采购机制。不过，向县级行政单位及医疗机构的资金拨付存在延迟，采购流程也相对冗长。
生殖与儿童健康服务：国内与捐赠方资金被重新调配至疫情防控工作中，导致相关项目活动被迫延期，同时也对计划生育服务的供给造成了负面影响。
全民健康覆盖（Universal Health Coverage, UHC）规划：由于工作重心转向疫情防控，全民健康覆盖相关活动的优先级受到了负面影响。与之相对的是，针对卫生领域的战略性投资被证实是强化卫生系统韧性的有效路径。
强化卫生系统以提升其应对突发公共卫生事件的韧性，需要投入大量的财力与非财力资源。卫生筹资安排是决定卫生系统对COVID-19及未来大流行病的适应能力、灵活性与响应速度的核心要素。