Budget monitoring and accountability mechanisms.

Public Finance Management (PFM) practices influence the attainment of health system goals. PFM processes are implemented within the budget cycle which entails the formulation, execution, and monitoring of government budgets. Budget monitoring and accountability actors, structures, and processes are important in improving the efficiency of health systems. This study examined how the budget monitoring and accountability processes influence the efficiency of county health systems in KenyaWe conducted a qualitative case study of four counties in Kenya selected based on their relative technical efficiency. We collected data using in-depth interviews with health and finance stakeholders (n = 70), and document reviews. We analyzed data using a thematic approach, informed by our study conceptual framework. We found that weak budget monitoring and accountability mechanisms compromised county health system efficiency by a) weakening the effective implementation of the budget formulation and execution steps of the budget cycle, b) enabling the misappropriation of public resources, and c) limiting evidence-informed decision-making by weakening feedback that would be provided by effective monitoring and accountability. Devolution meant that accountability actors were closer to implementation actors which promoted timely problem solving and the relevance of solutions. Internal audit practices were supportive and provided useful feedback to health system managers that facilitated improvements in budget formulation and execution. The efficiency of county health systems can be improved by strengthening the budget monitoring and accountability processes. This can be achieved by increasing the population’s budget literacy, supporting participatory budgeting, synchronizing performance and financial accountability, implementing the existent budget monitoring and accountability mechanisms, rewarding efficiency, and sanctioning inefficiency.

公共财政管理（Public Finance Management, PFM）实践会影响卫生系统目标的实现。预算周期涵盖政府预算的编制、执行与监控，预算监控与问责的相关主体、组织架构及实施流程，对提升卫生系统运行效率具有重要意义。本研究探讨了预算监控与问责流程如何影响肯尼亚各县卫生系统的运行效率。本研究针对肯尼亚4个基于相对技术效率筛选出的县开展了定性案例研究，通过对卫生与财政领域利益相关方开展深度访谈（n=70）及文件审阅收集数据，并基于研究概念框架采用主题分析法对数据进行分析。研究发现，薄弱的预算监控与问责机制通过三方面损害了县卫生系统的运行效率：一是削弱了预算周期中预算编制与执行环节的有效落地；二是滋生了公共资源挪用问题；三是削弱了有效监控与问责本应提供的反馈渠道，限制了循证决策的开展。权力下放使得问责主体更贴近执行主体，这有助于及时解决问题并提升解决方案的针对性。内部审计实务可为卫生系统管理者提供有效反馈，助力其优化预算编制与执行工作。县卫生系统的运行效率可通过强化预算监控与问责流程得以提升，具体举措包括提升民众的预算素养、支持参与式预算编制、统筹绩效与财务问责机制、落实现有预算监控与问责制度、对高效履职行为予以激励，并对低效行为进行惩戒。