SOCW 6070 WK 9 Discussion 1: Funding through Grants

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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 health-

care 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 priority-

setting 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 hos-

pitals we applied a published evaluative framework that was de-

veloped from a review of literature on priority-setting evaluation

(Barasa et al. 2015a). Our evaluative framework is based on the ar-

gument 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 well-

known ‘accountability for reasonableness’ framework (AFR)

(Daniels 2008), as well as consequentialist conditions of priority-

setting (Barasa et al. 2015a). This integrated evaluative framework

makes the following proposals (Figure 1) : First, given that priority-

setting 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 traded-

off against equity. To achieve equity, the distribution of resources

should be determined by need rather than other factors such as abil-

ity to pay, favouritism or political consideration. Third, other inter-

mediate outcomes of priority-setting processes are also important.

These include: (1) Stakeholder satisfaction; (2) Stakeholder under-

standing; (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 commu-

nity values.

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

and interpretations that are relevant to policy and pragmatic recom-

mendations. 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.

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 man-

agement 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 account-

ants and maintenance personnel), all of whom were answerable to

the heads of their respective departments. These heads of depart-

ments 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. phar-

macy 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 med-

ical 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 man-

agers) and senior managers. Second, there was an executive expend-

iture 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 hos-

pital administrative officer.

Budgeting and planning process. The budgeting and planning pro-

cess 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 hos-

pitals was guided by KEPH, hospital managers had autonomy to al-

locate 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 de-

partmental needs and present these to the HMT. The HMT then de-

liberates 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

Table 1. Number of participants selected in each hospital under

each category

National-level key informants 5

Hospital A Hospital B

Senior managers 6 6

Mid-level managers 22 19

Front-line practitioners 7 8

Hospital sub-total 35 32

Study total 72

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and subsequently presented to the HMC for review and approval.

Budgets approved by the HMC should then be submitted to the re-

gional 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 hos-

pitals. 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 pro-

cess, 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 fin-

ished 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 impli-

citly employed, that influenced budget allocation decisions in hos-

pitals. To get an idea of the prominence of criteria used in the case

study hospitals, we developed a word cloud by identifying decision-

making 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

Figure 2. Hospital Organogram

Figure 1. Framework for evaluation for priority setting

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services that generated more revenue from user fee collections were

prioritized over departments that generated less revenue and subse-

quently 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, re-

sources had to be allocated in a manner that assured further gener-

ation of revenues:

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 crite-

ria 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 com-

petence 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 hos-

pital could not run without them. The perceived medical need in the

hospital’s catchment area was also a determinant of hospital alloca-

tions. The need was however based on the volume of patients seek-

ing 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 rela-

tionships and mutual benefit between the middle-level managers and

the senior managers.

Allocations depend on your relationship with the hospital admin-

istrators. . .we mean in life sometimes things work because of re-

lationships 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 se-

nior managers (EEC), this provided an opportunity for the EEC

managers to leverage on their unique position to favour their depart-

ments 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 bargain-

ing 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 alloca-

tion decisions were unfair, in Hospital B the feeling was that alloca-

tions 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 proce-

duralist conditions.

The use of consequentialist principles.

Efficiency and equity. Hospital managers were unfamiliar with mech-

anisms such as cost-effectiveness analysis (CEA) and program budg-

eting and marginal analysis (PBMA). When the basics and rationales

of these methods were explained to them, they responded that al-

though the methods were potentially useful in decision-making, they

lacked the technical skills and data required. However, in both hos-

pitals, 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 affordabil-

ity of competing priorities, managers were recognizing budget limi-

tations and the need to make decisions such that the hospital could

get the most out of available resources.

Figure 3. Word cloud of priority-setting criteria in the case study hospitals

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In both case study hospitals, the dominance of revenue maxi-

mization 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 com-

pared to departments that generated user fee revenues. This practice

meant that budget allocations were inequitable. Further, the re-

ported 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 satisfaction. The level of satisfaction with the budgeting

and planning process varied between hospitals. In Hospital A, stake-

holders (senior and middle level managers, and frontline practi-

tioners) were not satisfied with the budgeting and planning process

because the process was generally not inclusive, leaving most stake-

holders 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 disgrun-

tled. In Hospital B, the stakeholders reported having some level of

satisfaction with the budgeting and planning process. While they

were unhappy with the limited availability of resources, they seemed

to understand the scarcity situation. It appeared that this general sat-

isfaction with the process was due to the fact that they were included

in the budgeting and planning process. However, managers of de-

partments with low revenue generating potential, like in Hospital A,

were unhappy with the process.

Stakeholder understanding (awareness). The level of understanding

varied across stakeholders and was related to their level of engage-

ment. 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 hos-

pitals, budgeting and planning processes did not result in shifted re-

sources. 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 dy-

namics of resource needs.

Implementation of decisions. The implementation of budgeting and

planning decisions was fairly similar between the case study hos-

pitals. The planning processes in both hospitals were considered to

be mainly an activity on paper that was hardly implemented in prac-

tice. A number of reasons, which we have reported elsewhere, led to

the lack of implementation of decisions including the lack of re-

sources, 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 responsi-

bilities, and the lack of strong internal accountability mechanisms

(Barasa et al. in press).

Compliance with proceduralist conditions.

Stakeholder engagement. The degree of stakeholder engagement var-

ied 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 pro-

cess. 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 depart-

ments can get. Middle level manager, Hospital B

In both hospitals, however, frontline clinicians rarely partici-

pated 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 empower-

ment 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 meet-

ings, 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 pro-

cess (clinicians and the community) were clearly not empowered to

contribute to decision making either.

Transparency. The extent to which the budgeting and planning pro-

cess 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 se-

lected 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 plan-

ning 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 indi-

vidually sought them out.

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Use of quality information. In both case study hospitals, decisions were

rarely made based on information/evidence. Information was gath-

ered using formal channels such as the hospital management infor-

mation system but ignored. Decision makers often used their gut

feeling and hearsay as the basis for decision-making. When informa-

tion was used, the use was more symbolic rather than functional.

Decisions were first made and then information was sought to jus-

tify the decisions. One of the reasons given for the low use of infor-

mation was that the quality of information available was

questionable. Managers reported that data captured in clinic regis-

ters often had gaps and did not capture all events. They also com-

plained that the data captured in clinic registers were inaccurate.

Revisions. In both case hospitals the budgeting and planning process

did not have a provision for a formal appeals and revision process.

Once the quarterly budget or the AWPs had been prepared and

approved, they could not be changed or altered over the course of

the planning period. This meant that the decision-making process

was inflexible and could not be improved with emerging informa-

tion. It also meant that there was no formal avenue for parties to

contest planning and budgeting decisions.

Community values. In both case hospitals, community views were ob-

tained through two mechanisms namely the suggestion box and

community representatives in the HMC. Both mechanisms were

however felt to be ineffective as mechanisms for channelling com-

munity views. In both case study hospitals, the suggestion box was

hardly ever opened by the hospital administration. The incorpor-

ation of community representatives in the HMC was also shown to

be an ineffective mechanism for obtaining community values in both

hospitals. This mechanism was shown to have two main shortcom-

ings. First, the method of appointing community representatives

into the committee was not thought to be transparent and inclusive.

Senior hospital managers were perceived to influence the selection

process to appoint preferred individuals, who were then thought to

simply ‘rubber stamp’ hospital decisions. The community represen-

tatives in this committee were therefore not empowered to ask ques-

tions and contribute to decision-making.

Discussion

This study is the first in Kenya - and one of very few in LMIC set-

tings - that examines priority-setting processes in hospitals. One of

the key findings was the lack of alignment of the budgeting process

and the annual work planning process. Non-alignment between

budgets and sector priorities has been identified as a reason for

Kenya failing to achieve health sector targets (Tsofa et al. 2015).

This non-alignment appears to be a downstream manifestation of

the observed lack of coordination and harmonization of the budget-

ing and planning processes for the health sector with the central

MOH (Tsofa et al. 2015). It is imperative that planning and budget-

ing processes are integrated and harmonized by, for example, ensur-

ing that the same set of actors and administrative units within the

county departments of health drive the process, and by harmonizing

the timelines for the two processes such that budgeting is carried out

only after (and therefore draws from) the planning process.

A second observation was the lack of clarity about the roles and

composition of the different decision -making organs in the case hos-

pitals. The importance of clarifying roles of decision-making bodies

has been highlighted in priority-setting literature (Gibson et al.

2004). Role clarity in the county hospitals could be improved by

developing official hospital organograms with clear terms of refer-

ence for each position in the structure and specification of the com-

position of management committees.

A third observation concerns the appropriateness of the criteria

used to set priorities. It has been pointed out in literature that the

criteria used to set healthcare priorities should be clearly defined

and understood by stakeholders and decision-makers (Gibson et al.

2004). The dominant criteria used to set priorities in both case study

hospitals are the revenue generating potential of the department.

These criteria are seen to promote the inequitable allocation of

budgets which resulted in frustration and reduced motivation among

hospital staff (Barasa et al. in press). The use of informal criteria to

set priorities also stands out as an area of concern. While this obser-

vation was more prominent in Hospital A, it was minimized in

Hospital B largely because of the leadership style of the hospital

superintendent (Barasa et al. in press). The use of informal criteria

to set hospital priorities is consistent with findings in a number of

settings. For example, in a case study of priority-setting practice in a

public hospital in Uganda, it was reported that departments whose

leaders knew how to ‘lobby’, ‘make noise’, ‘quickly use up their re-

sources’, or ‘make their case’ were usually prioritized (Kapiriri and

Martin 2006). In these settings, it was reported that the absence of

data led to the use of informal or arbitrary considerations in decision

making (Gordon et al. 2009). While this is also true of the case study

hospitals, it also emerged that multiple additional factors had led to

the use of informal criteria including the absence of explicit guide-

lines to guide budgeting and planning. The use of informal criteria is

seen to result in perceptions of unfairness. The case study hospitals

could minimize these unwanted consequences by adopting and im-

plementing systematic and explicit priority-setting criteria that hos-

pital actors agree on. Strengthening hospital information systems to

provide reliable information for decision-making could also reduce

the use of informal decision-making criteria.

A number of key issues emerge from the evaluation of the budg-

eting and planning process in the case hospitals. The use of eco-

nomic methods such as CEA and PBMA was hampered by a lack of

both technical capacity and reliable data. This is consistent with the

literature on priority-setting in other settings (Barasa et al. 2015b;

Hauck et al. 2004). Managers in the case study hospitals none-the-

less appreciated the rationale of incorporating economic consider-

ations in priority-setting processes and attempted to do this by using

the affordability criteria. This was perhaps a more pragmatic ap-

proach in this and similar settings: priority-setting processes in set-

tings with resource, capacity and data challenges could incorporate

efficiency considerations by assessing the affordability and budget

impact of competing priorities alongside their effectiveness. Further,

while equity was a concept that hospital actors related to, there was

no systematic attempt to incorporate it. It is imperative that there is

an explicit requirement that allocation of resources in hospitals be

based on need, give priority to the worse off and is transparent

about where such considerations are traded off with efficiency.

With regard to intermediate outcomes of the budgeting and plan-

ning processes, stakeholders in Hospital B were more satisfied and

better understood the budgeting and planning processes compared to

Hospital A because the process in the latter was more inclusive and

deliberative, eliciting perceptions of transparency and fairness. The

fact that stakeholders were included in Hospital B made them appre-

ciate the reality of resource scarcity which in turn resulted in their

being more understanding of the situation. This highlights the rela-

tionship between procedural conditions and intermediate outcomes

and the importance of both. In both hospitals, however, the budgeting

and planning processes often did not lead to shift resources due to the

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fact that hospitals relied on historical allocations. The use of historical

budgeting means that the hospital budgeting and planning process

was not responsive to the dynamic healthcare priorities of the com-

munities that they serve. It also served to entrench historical inequities

in the allocation of resources within the hospitals. To improve

priority-setting, hospitals should adapt criteria that are responsive to

hospital needs and health system goals (such as burden of disease, ef-

fectiveness and cost-effectiveness, equity) rather than historical budg-

eting. The implementation of planning decisions in both case study

hospitals was also seen to be unsatisfactory. This was attributed to,

among others, non-alignment of budgets and plans and lack of in-

ternal accountability mechanisms to follow up and ensure that plans

and budgets are implemented. It is imperative that hospitals

strengthen their internal accountability mechanisms by, among

others, introducing and enforcing a system of tracking and monitor-

ing the implementation of budgets and holding hospital managers ac-

countable by a system of rewards and sanctions.

With regard to procedural conditions, the case hospitals could

improve their budgeting and planning processes by ensuring that the

relevant range of stakeholders are included in the process. Notable

exclusions in both hospitals were frontline clinicians and the public.

This is consistent with the literature on hospital level priority-setting

(Barasa et al. 2015b). This exclusion calls into question the legitim-

acy of the priority-setting processes and resulted in perceptions of

unfairness (Barasa et al. in press). One way of improving the inclu-

sivity of the process in Kenyan county hospitals is to ensure that ac-

tual budgeting decisions are made in a more inclusive decision-

making organ, such as the HMT, rather than the more exclusive

EEC. Closely related to this, the range of actors excluded from

budgeting and planning processes also appear to be less empowered

to contribute to decision-making. This exclusion is a function of un-

clear or sometimes lacking guidelines and systems and also of micro-

practices of power among hospital actors (Barasa et al. in press.). It

is imperative that hospitals specify systematic priority-setting proc-

esses that clearly outline the procedure, roles of actors, and compos-

ition of decision-making organs. Such a system should ensure that

the relevant range of actors are included, the decision-making pro-

cess is deliberative and mechanisms to empower actors are put in

place (Barasa et al. in press). As has been discussed elsewhere, hos-

pital leadership also plays an important role in ensuring the effect-

iveness of deliberative processes by actively ensuring that processes

are inclusive and managing the power dynamics among actors with

varying levels of influence (Barasa et al. in press). Transparency is

also seen to be a sticky issue in both hospitals with perceptions of

lack of transparency being worse in Hospital A. To improve trans-

parency, case study hospitals will need to improve communication

and provide information about hospital budgeting decisions, and

their rationales to all relevant actors. This information should be

made easily accessible to these actors, and also actively pushed to

them. In both case study hospitals, budgeting and planning processes

did not use evidence to make decisions but rather relied on personal

experience and hunches. Improving the quality of information, in-

formation systems, and requiring that budgeting and planning deci-

sions be backed by evidence would improve this in the short term. In

the long term, however, there is a need to focus on changing the de-

cision-making culture of hospital managers to place more import-

ance on evidence based decision making. Related to this, and

consistent with findings in most settings, there is no formal process

for revisions. For hospital priority-setting processes to be responsive

to the changing dynamics of information and needs, it is imperative

that there is a mechanism that allows for budgets and plans to be

amended in light of new information.

In both case study hospitals, there is no systematic and effective

mechanism to elicit and incorporate community values in the budg-

eting and planning process. If we accept the idea that hospitals are a

social institution, then the lack of a mechanism to incorporate com-

munity values begs the question of the legitimacy and responsiveness

of the hospital budgeting and planning processes (Barasa et al. in

press). County hospitals in Kenya should incorporate participatory

community engagement mechanisms such as the incorporation of

community members in hospital planning committees, the use of

citizen juries (Lenaghan 1999) or planning cells (Abelson et al.

2001). The selection of community representatives in these mechan-

isms must however be seen to be transparent and fair. The proposal

for implementing and/or strengthening community engagement in

decision making is not a new thing in Kenya. The new Kenyan con-

stitution requires that decision making at both the national and

county levels involve and engage the public for their inputs

(Government of Kenya 2010). Further, the Kenyan public finance

law prescribes a mechanism that requires that the public budgeting

processes at the national and county levels organize public forums

to share and debate proposals before finalization of budgets

(Government of Kenya 2012). Extending this practice to health sec-

tor priority-setting therefore has a precedent from public finance

practice in Kenya.

Conclusion

In this paper, we have presented a description and evaluation of the

budgeting and planning process in county hospitals in Kenya. It is

clear that to improve priority-setting practices, decision makers in

charge of these hospitals will need to focus their attention not only

on the content and outcomes of priority setting but also - equally im-

portant - on the process. Fulfilling the consequentialist and proce-

duralist conditions of our evaluative framework, especially is

resource constrained settings, may be challenging, and will require

making difficult trade-offs. We recognize these constraints and rec-

ommend that when making these decisions, in addition to consider-

ing the required resources, decision makers should also consider the

merits of implementing a process that incorporates these conditions

such as; improvement of the legitimacy of the decisions, strengthen-

ing the responsiveness of priority-setting decisions to local needs,

minimizing the range of disagreements, and improving the quality of

priority-setting decisions. Decision makers may therefore need to

consider feasible ways of implementation while considering context.

For example, hospitals could start by incorporating some of the con-

ditions, and then progressively add the other elements over time.

Also, innovative ways could be used to improve feasibility and af-

fordability. For example, a cost-effective strategy to incorporate

community engagement would perhaps be to integrate hospital com-

munity engagement initiatives with those already funded by the

counties rather than having individual hospital initiatives.

One of the limitations of the study is that we did not interview

community representatives, who are a key stakeholder in priority-

setting processes. While interviewing community representatives

were beyond the scope of the study, it would have enriched our find-

ings especially with regard to their role and experiences of hospital

priority-setting processes. Another limitation is the inability to gen-

eralize findings of a case study. This not-withstanding, this study, in

line with the intentions and characteristics of case study method-

ology, provides in-depth insights that can be considered and tested

in comparable settings (Gilson et al. 2011).

336 Health Policy and Planning, 2017, Vol. 32, No. 3

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