PLOS Global Public Health · 12 authors, 9 centres
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This qualitative case study of four Kenyan counties found that weak budget monitoring and accountability mechanisms compromised county health system efficiency by weakening budget cycles, enabling resource misappropriation, and limiting evidence-informed decision-making.
The study used a qualitative case study design, collecting data via in-depth interviews with 70 health and finance stakeholders and document reviews across four Kenyan counties selected for their relative technical efficiency. Thematic analysis revealed that weak budget monitoring and accountability processes undermined efficiency in several ways: they weakened budget formulation and execution, facilitated misappropriation of public resources, and limited feedback for evidence-informed decision-making. Positively, devolution placed accountability actors closer to implementation, enabling timely problem-solving, and internal audit practices provided useful feedback. Limitations include the selection of only four counties and the absence of data from patients or civil society. The findings imply that strengthening these processes through measures like increasing budget literacy, supporting participatory budgeting, and enforcing sanctions and rewards could improve efficiency.
