Financial Determinants of Effective Hypertension and Diabetes Care in Rural Primary Health Facilities in Kisumu, Kenya: A Mixed-Methods Study

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Despite devolution of health services to county governments in 2013, financing for NCD management at the primary health care (PHC) level remains weak. This study examines financial determinants shaping hypertension and diabetes care in PHC facilities within a devolved county health system in rural Kisumu County, Kenya. Methods We conducted a convergent parallel mixed-methods cross-sectional study in seven public PHC facilities in Seme Sub-County. Quantitative data were collected via structured questionnaires and retrospective document review of financial records (January–August 2024). Qualitative data were gathered through in-depth interviews with facility in-charges exploring planning, budgeting, and resource allocation. Descriptive statistics were produced in STATA v16; qualitative data were analyzed thematically in R. Results All seven facilities prepared annual workplans and budgets, but none achieved comprehensive NCD-specific planning (workplan + budget + dedicated NCD budget line). Funding sources were narrow: 71.4% (n = 5) depended on NHIF reimbursements and donor support, while only 28.6% (n = 2) received direct county funding; 57.1% (n = 4) relied on only two funding streams. Although all facilities held bank accounts, none had formal financial autonomy and expenditures required county-level approval, typically taking 3–4 weeks (57.1%, n = 4) to over two months (28.6%, n = 2). Combined with unreliable central supplies, this lack of autonomy meant facilities could not procure locally when stockouts occurred; consequently 85.7% (n = 6) reported frequent medication stockouts. Facility in-charges attributed these failures to inadequate, unpredictable funding and centralized approval processes that prevented timely local procurement. Conclusions PHC facilities in this rural county operate under severely constrained financial conditions that undermine effective NCD care. Strengthening facility financial autonomy, instituting ring-fenced NCD budget lines, diversifying financing, and streamlining disbursement and emergency procurement mechanisms are urgent priorities to reduce stockouts and advance equitable chronic care under Kenya’s UHC agenda. Health financing Primary health care Noncommunicable diseases Hypertension Diabetes Devolution Kenya Financial autonomy Medication stockouts Figures Figure 1 Background Noncommunicable diseases (NCDs) constitute a rapidly escalating public health crisis in sub-Saharan Africa, with hypertension and diabetes representing particularly urgent challenges. Globally, NCDs account for over 70% of all deaths, disproportionately affecting low- and middle-income countries (LMICs) [ 1 , 2 ]. In Kenya, NCDs have surpassed communicable diseases as the leading cause of mortality, with cardiovascular diseases responsible for over 27% of all deaths [ 3 ]. National surveys indicate that approximately 26% of adults have elevated blood pressure and 5.6% have raised blood glucose levels [ 4 ], creating a substantial and growing demand for chronic disease management services. Effective management of hypertension and diabetes requires sustained access to screening, diagnosis, treatment, and long-term monitoring with affordable medicines [ 5 , 6 ]. Delivering these services depends critically on adequate and predictable health financing [ 7 , 8 ]. In this study, effectiveness is operationalized in line with the Kenya Health Financing Strategy (2020–2030), which identifies effectiveness and efficiency as core strategic principles guiding health-financing reforms [ 9 ]. Effectiveness reflects the extent to which financing mechanisms enable facilities to achieve desired health outcomes through: (1) continuous availability of essential medicines and diagnostics; (2) continuity of patient care and follow-up; (3) prevention of severe complications requiring hospitalization; and (4) responsiveness to patient needs. Other guiding principles such as appropriateness, transparency, social solidarity, and equity are evaluated in this study within the context of NCD financing at the primary health-care level. According to the World Health Organization’s health-financing framework, the capacity of a health system to deliver quality, accessible services without financial hardship depends on how resources are collected, pooled, and purchased [ 9 , 10 ]. In Kenya, health financing occurs through several channels, including government tax-based allocations, social health insurance (previously the National Hospital Insurance Fund [NHIF], replaced in 2024 by the Social Health Authority [SHA]), donor contributions, and out-of-pocket payments. However, the flow and management of these resources at the facility level largely determine service delivery capacity, particularly for chronic conditions that require sustained care [ 8 , 11 ]. Primary health care (PHC) facilities form the foundation of Kenya’s health system under the Kenya Essential Package for Health (KEPH) framework. The framework defines a tiered system of increasing service complexity: Level 1 (community health units) provide health promotion and referral linkages; Level 2 (dispensaries) offer basic outpatient care and NCD screening; Level 3 (health centres) provide expanded outpatient, laboratory, and maternal care; and Level 4 (sub-county hospitals) deliver comprehensive services including inpatient and specialized NCD management. Each successive level requires greater financial and human-resource inputs, with financing expected to align proportionately with function. However, PHC facilities (Levels 2–4) often operate under resource constraints that limit their ability to provide consistent NCD services [ 12 , 13 , 14 ]. Kenya’s health sector underwent major transformation with the 2010 Constitution and 2013 devolution of governance, which created a two-tier system comprising the national government and 47 semi-autonomous county governments [ 15 ]. Counties assumed responsibility for delivering services at community and primary levels, while the national government retained policy and regulatory oversight [ 9 ]. Devolution was intended to enhance responsiveness, accountability, and efficiency by bringing decision-making and resources closer to populations [ 13 , 16 ]. Despite these objectives, devolution has been accompanied by persistent financing challenges: fragmented planning and budgeting processes, delayed and unpredictable fund flows, and wide variation in county prioritization [ 17 , 18 , 19 ]. Although health-sector allocations increased from 6% of the national budget in 2015 to 11% in 2023 [ 17 – 20 ], these remain below the 15% Abuja target and insufficient to meet the escalating NCD burden. A pivotal reform shaping health-facility financing was the Public Finance Management (PFM) Act of 2012, which inadvertently recentralized financial authority at county level. Before the Act, the Health Sector Services Fund (HSSF) had enabled facilities to retain and manage revenues locally, enhancing flexibility to procure essential commodities during supply shortages. However, following PFM Act implementation, most counties required all facility funds to pass through county treasuries, with expenditures subject to county-level approval. While designed to improve accountability, this shift reduced operational flexibility, delaying procurement and undermining timely response to medication stockouts or equipment failures, issues critical to chronic disease management [ 16 , 20 , 21 ]. The ongoing tension between financial accountability and local autonomy remains a central governance challenge within Kenya’s devolved health system. Financing constraints at the facility level have direct implications for NCD service delivery. Inadequate and unpredictable funding compromises the consistent availability of medicines, diagnostics, and trained personnel, all vital for effective chronic care [ 22 , 23 ]. Unlike vertical programs for HIV, TB, and malaria that benefit from earmarked funding, NCD programs lack ring-fenced budget allocations and are integrated into general PHC budgets, leaving them vulnerable to competing priorities. Limited data on NCD burden, cost, and utilization further weaken their case during budgeting cycles [ 14 , 21 ]. Consequently, NCD services frequently suffer from chronic underfunding and irregular supplies of essential drugs. Non-state actors contribute variably to NCD financing at the county level. Development partners such as Danida have supported selected counties, while social health insurance reimbursements through NHIF/SHA offer limited financial protection. However, delays in reimbursements and unpredictable payment amounts continue to destabilize facility operations for chronic disease management [ 12 , 24 , 25 ]. These systemic financing gaps have significant implications for Universal Health Coverage (UHC) and health equity. Effective UHC requires that all individuals, regardless of socioeconomic or geographic status, have access to quality health services without financial hardship. Yet, the current financing architecture in Kenya’s devolved system limits equitable access to essential chronic disease services particularly in rural areas where facilities depend on narrow, unpredictable revenue streams and have limited fiscal autonomy. Despite multiple financing reforms and the growing burden of NCDs, empirical evidence on how financing mechanisms at the PHC facility level affect hypertension and diabetes service delivery remain limited. Previous studies have addressed health-system financing broadly [ 13 , 20 , 21 ], but have rarely examined facility-level processes or incorporated managerial perspectives. Understanding how revenue sources, budgeting processes, and resource allocation decisions interact to shape service effectiveness is critical for informing equitable health-financing reforms. Kisumu County, in western Kenya, offers a relevant context for this inquiry. The county faces a high prevalence of hypertension and diabetes and is piloting innovations such as Primary Care Networks (PCNs) and eHealth initiatives aimed at strengthening PHC coordination. Within this setting, rural sub-counties like Seme experience the dual challenge of implementing reforms amid limited fiscal capacity and infrastructure. This study therefore investigates how financing arrangements influence effective hypertension and diabetes management in Seme Sub-County’s PHC facilities. Specifically, the study aims to: (1) identify sources of funding for NCD management; (2) examine planning and budgeting processes; (3) assess allocation and utilization of financial resources; and (4) analyze how financing mechanisms influence the effectiveness of NCD service delivery. Findings aim to provide actionable evidence to inform Kenya’s ongoing pursuit of UHC and strengthen financial resilience within devolved health systems. Methods Study design We conducted a convergent parallel mixed-methods cross-sectional study using a multi-site case study approach [ 26 ]. Quantitative and qualitative data were collected concurrently, analyzed separately, and integrated during interpretation to generate complementary insights into facility financing mechanisms. The design was QUAL-dominant at the analytical stage because the small facility sample size (N = 7) limited statistical inference, while qualitative data provided essential contextual understanding [ 27 ]. Both data types were, however, equally valued during data collection and interpretation. Study setting The study was conducted in Seme Sub-County, a rural sub-county of Kisumu County, western Kenya. Kisumu was purposively selected due to its high prevalence of hypertension and diabetes and its ongoing implementation of Primary Care Networks (PCNs) and eHealth initiatives aimed at strengthening coordination between community and facility levels. These reforms provided a relevant context for examining facility-level financial mechanisms within a devolved health system. This research was nested within the broader VLIR-UOS + JOOUST SP3 Project, which seeks to strengthen NCD service delivery in the Lake Basin region. The VLIR project provided the sampling frame and facilitated access to study sites but did not influence this study’s research question, instrument design, data collection, or analysis. Data were collected between January and August 2024, before full implementation of VLIR interventions, providing a baseline on financing mechanisms before system strengthening activities commenced. Study population and sampling The target population comprised public PHC facilities providing NCD services in Seme Sub-County. In consultation with sub-county health officers, eight facilities were initially identified. Seven facilities ultimately participated in the study after one facility declined due to administrative constraints. These seven facilities were purposively sampled based on the following criteria: (1) the facility must be a public entity under county government management; (2) the facility must be actively providing services for both hypertension and diabetes; and (3) the facility management team must be willing to participate. While this sample size is small and precludes statistical generalizability, it represents all major public PHC facilities providing NCD services in the sub-county across all KEPH levels (Levels 2–4), providing comprehensive local coverage. The facilities exhibit typical characteristics of rural primary health care facilities in western Kenya: government-owned, county-managed, serving predominantly rural populations, and operating under similar policy and financing frameworks. These characteristics enhance transferability of findings to similar rural contexts in Kenya, though variations in county governance capacity and resource availability must be acknowledged. At each facility, key informants were purposively selected based on their roles and direct involvement in financial management or NCD service delivery. Primary informants were facility in-charges, who possessed comprehensive knowledge of facility operations, budgeting processes, and service delivery challenges. Conceptual framework The study was guided by the World Health Organization (WHO) health financing framework, adapted to the facility level. This framework conceptualizes NCD care effectiveness as influenced by four interrelated financial dimensions[ 24 , 28 ]. Figure 1 illustrates the conceptual framework guiding this study. The framework posits that NCD care effectiveness is influenced by a cascade of financial determinants organized into four interrelated dimensions: (1) sources of financing (diversity and mix of funding sources including government, user fees, NHIF, Facility Improvement Fund (FIF) - a conditional grant designed to support facility-level infrastructure and operational improvements, donors; reliability and consistency of inflows; share of revenue allocated to NCDs); (2) planning and budgeting (planning processes and NCD inclusion; NCD-specific budgeting and transparency; alignment with NCD burden); (3) resource allocation (predictability of allocations; facility autonomy and flexibility; NCD prioritization in allocation); and (4) financial resource utilization (efficiency of expenditure in procurement and disbursement; accountability and oversight; responsiveness to NCD needs). These dimensions are moderated by health facility characteristics (size, staffing, facility type/KEPH level) and collectively determine the dependent variable: effectiveness of hypertension and diabetes care, measured through availability of essential NCD commodities, access to comprehensive NCD services, quality and continuity of care, and equity in service provision. Data collection Data collection occurred between January and August 2024, prior to the full implementation of Kenya's 2023 Social Health Insurance Act (enacted November 2023). At the time of data collection, the National Hospital Insurance Fund (NHIF) remained the primary social health insurance mechanism, though the Social Health Authority (SHA) that replaced NHIF had been legally established and was in early implementation phases. The SHA began full operations in October 2024, after our data collection was complete. All data therefore reflect the financing landscape under the NHIF regime and the transition period to SHA. Quantitative data collection Quantitative data were collected using a structured questionnaire adapted from the WHO Package of Essential Noncommunicable Disease Interventions (PEN) framework [ 5 , 29 ] and health facility financing assessment tools applied in similar Kenyan contexts [ 14 ]. The tool was modified to include additional variables specific to financial autonomy, NCD-specific budgeting practices, and resource allocation mechanisms at the primary health care level, reflecting Kenya's devolved health financing architecture and the policy context of county-managed health facilities. Modifications included detailed questions on funding source diversity (NHIF, county allocations, Facility Improvement Fund, donor support, user fees), expenditure approval processes and timelines, medication stockout frequency and causes, and perceived effectiveness of different financing mechanisms for NCD care. The final English version of the questionnaire used in this study is provided as a supplementary file (Additional File 1). The tool captured information on facility characteristics, funding sources, planning and budgeting practices, resource allocation, and NCD service availability. Data were collected using KoboToolbox on tablets, enabling real-time validation. Financial information was extracted through retrospective review of records, including bank statements, budget reports, expenditure ledgers, and procurement receipts, from January to August 2024. Structured interviews with facility in-charges were conducted to clarify incomplete records and validate financial data, especially regarding funding sources and fund-approval timeframes. Qualitative data collection Qualitative data were collected through in-depth, face-to-face interviews with facility in-charges using a semi-structured interview guide developed for this study (Additional File 1). The guide was informed by the WHO health financing framework [ 24 , 28 ] and health facility financing literature in devolved contexts [ 14 , 30 , 31 ], with questions tailored to explore how financing mechanisms specifically affect NCD service delivery in rural primary health care settings. The interview guide explored: (1) sources and adequacy of funding for NCD services; (2) planning and budgeting processes and the extent to which NCDs are prioritized; (3) challenges in fund access, allocation, and utilization; and (4) the perceived impact of financing mechanisms on NCD service delivery quality and patient outcomes. Interviews were conducted in English (the language of professional health care communication in Kenya), lasted approximately 45–60 minutes, and were audio-recorded with informed consent. The interview guide used open-ended questions such as "Can you describe how your facility plans and budgets for NCD services?" followed by probing questions to explore mechanisms and consequences (e.g., "How does this affect your ability to manage patients with diabetes?"). An observation checklist was also used to systematically document the availability and functional status of essential NCD resources, including medications (specifically checking for common antihypertensives and antidiabetics listed in WHO PEN), blood pressure apparatus, glucometers, test strips, and patient registers/management tools. Data management and analysis Quantitative analysis Quantitative data were entered and cleaned in Microsoft Excel before being exported to STATA version 16 (StataCorp, College Station, TX, USA) for analysis. Given the small sample size (N = 7 facilities), analysis focused on descriptive statistics. Frequencies, percentages, means, and ranges were calculated to summarize facility characteristics, funding sources, planning and budgeting practices, financial autonomy indicators, and NCD service readiness measures. Results were tabulated to facilitate pattern identification and comparison. Qualitative analysis Audio recordings were transcribed verbatim and transcripts were validated against original recordings for accuracy. Transcripts were imported into R software for thematic analysis following Braun and Clarke's approach [ 32 , 33 ]. Analysis proceeded iteratively through several stages: familiarization with data through repeated reading; generation of initial codes based on the study's conceptual framework and research questions; collation of codes into candidate themes; review and refinement of themes; and definition and naming of final themes. The qualitative analysis aimed to uncover the mechanisms, contextual factors, and perspectives that explained the quantitative patterns observed. Two researchers independently coded a subset of transcripts to enhance reliability, and discrepancies were resolved through discussion. Data integration Findings from quantitative and qualitative analyses were integrated during the interpretation phase through triangulation [ 33 ]. Qualitative themes were used to explain, contextualize, and provide depth to quantitative findings. For instance, quantitative data on medication stockout frequencies were interpreted in conjunction with qualitative explanations from in-charges regarding why stockouts occurred and their perceived consequences. This integration enhanced the validity and comprehensiveness of findings. Validity and reliability To ensure instrument validity, the questionnaire and interview guide were pre-tested at a health facility outside the study sample. Feedback was used to refine question clarity, structure, and cultural appropriateness. Tools were also reviewed by the research supervisory team, comprising experts in health financing and epidemiology, to ensure content validity. For the qualitative component, reliability was enhanced through consistent use of the interview guide, systematic probing techniques, and audio recording to minimize interviewer bias and data loss. Results Facility characteristics Seven primary health care (PHC) facilities participated in the study, all located in rural settings (Table 1 ). Facilities represented a mix of KEPH service levels: two Level 4 sub-county hospitals (28.6%), three Level 3 health centres (42.9%), and two Level 2 dispensaries (28.6%). No Level 1 community units were included because they do not provide clinical NCD care. Most facilities (71.4%, n = 5) had at least one staff member trained in NCD management. Although all possessed basic diagnostic equipment for hypertension and diabetes (blood pressure apparatus and glucometers), fewer than half (42.9%, n = 3) considered their equipment adequate for patient demand. Only two facilities (28.6%) reported generating internal revenue through user fees for NCD-related services. Table 1 Characteristics of participating primary health care facilities (N = 7) Characteristic Number (n) Percentage (%) Facility Level Level 4 (Sub- County Hospital) 2 28.6 Level 3 (Health Centre) 3 42.9 Level 2 (Dispensary) 2 28.6 Location Rural 7 100 NCD Service Readiness At least one staff member trained in NCDs 5 71.4 Has essential NCD diagnostic equipment 7 100 Reports equipment as adequate for patient load 3 42.9 Revenue Generation Generates revenue from user fees 2 28.6 Sources of facility funding for NCD care The main funding sources were NHIF reimbursements (71.4%, n = 5) and Danida support (71.4%, n = 5). Only two facilities (28.6%) received direct county government funds through the Facility Improvement Fund (FIF), and an equal number generated user-fee revenue (28.6%). No facility received NGO support other than Danida, and one facility (14.3%) obtained limited assistance from a private foundation (Table 2 ). Table 2 Sources of facility funding for NCD care (N = 7) Indicator Number (n) Percentage (%) A. Frequency of Funding Sources Mentioned NHIF 5 71.4 Danida 5 71.4 County Government / FIF 2 28.6 User Fees 2 28.6 M-PESA Foundation 1 14.3 Other NGO Support 0 0 B. Diversity of Funding Sources per Facility One Source 2 28.6 Two Sources 4 57.1 Three or More Sources 1 14.3 Note: N = 7 facilities. Sources are not mutually exclusive. More than half (57.1%, n = 4) relied on only two funding sources, while two facilities (28.6%) depended on a single source. Facility in-charges consistently reported that funds were insufficient and not designated for chronic disease management: “There are no designated funds for NCDs; everything goes into one pot.” (In-charge, Level 2) “We cannot specifically say this money is for NCDs. It’s all pooled for many competing needs.” (In-charge, Level 3) In-charges from facilities supported by Danida noted that reliance on donor funding created uncertainty, while those receiving NHIF reimbursements cited payment delays of two to four months, limiting planning capacity: “NHIF takes months to reimburse—sometimes three or four months. How do you plan with that?” (In-charge, Level 3) County government support was described as minimal or irregular: “County support is very limited. We depend mainly on what we generate or on NHIF, but even those are unpredictable.” (In-charge, Level 4) Planning and budgeting for NCD services All seven facilities reported preparing annual workplans and budgets, fulfilling administrative requirements (Table 3 ). However, none demonstrated comprehensive NCD-specific planning—that is, having a workplan, budget, and dedicated budget line for NCDs. However, when probed about NCD-specific planning, significant deficiencies emerged. While a majority (71.4%, n = 5) reported considering NCDs in their budgets, not a single facility (0%) achieved what we defined as comprehensive NCD planning having a work plan, a budget, and specific, dedicated consideration for NCDs within that budget. Table 3 Planning and budgeting practices for NCD services (N = 7) Planning & Budgeting Practice Number (n) % Facilities with annual work plans 7 100 Facilities with annual budgets 7 100 Facilities that specifically consider NCDs in the budget 5 71.4 Facilities with comprehensive NCD planning * 0 0 *Defined as having a work plan, a budget, AND specific consideration for NCDs The dominant perspective among in-charges (5/7) characterized the budgeting process as largely futile. Although the county health system nominally operates a "bottom-up" participatory budgeting approach, in-charges explained that their carefully prepared budgets were routinely set aside due to insufficient and unrestricted funding flows from the county government. As a result, budgets functioned as aspirational "wish lists" rather than operational financial management tools: "We budget but it's not actualized. These are just wish lists because the money is not enough to implement what we plan." (In-charge, Level 2 facility) "We prepare very detailed budgets with input from all departments, but at the end of the day, you get what is available, not what you budgeted for." (In-charge, Level 3 facility) "The process feels like an exercise in futility sometimes. We spend days preparing budgets that are never followed when the actual allocation comes." (In-charge, Level 4 facility) All in-charges emphasized the impossibility of meaningful NCD budgeting given the absence of dedicated NCD budget lines and overall resource scarcity. One in-charge quantified this inadequacy: "It doesn't [work], because you only budget with the money received from the facility. And the money is usually very inadequate. Sometimes you can even give NCDs 2,000 [Kenyan Shillings, approximately USD 15] for the whole year." (In-charge, Level 4 facility) "How do you budget for NCDs when you don't have dedicated funds? You end up just estimating what you might use from the general pot, but there's no guarantee." (In-charge, Level 2 facility) Most in-charges (6/7) also described limited facility input into final budget decisions despite the participatory process: "They say it's bottom-up, but our requests rarely make it to the final budget. The county decides what we get based on what's available, not what we need." (In-charge, Level 3 facility) "We participate in making the budget and presenting our needs, but the implementation is done by the county. They don't follow what we proposed." (In-charge, Level 2 facility) However, two in-charges from Level 4 facilities offered a more nuanced perspective. While acknowledging that NCD budgets were inadequate and often not fully actualized, they emphasized that the budget process did allow them to advocate for resources and occasionally influence allocation decisions: "It's not perfect, and we rarely get what we ask for, but at least we can present what we need. Sometimes we get a portion of what we requested, especially if we justify it well with data." (In-charge, Level 4 facility) "The budget process gives us a chance to advocate and make our case. Even if we don't get everything, we can push for priority items like NCD medicines and diagnostic equipment." (In-charge, Level 4 facility) Nevertheless, even these in-charges emphasized that unpredictable funding flows meant actual allocations rarely matched budgeted amounts, limiting their ability to plan effectively for NCD service needs. Financial autonomy and expenditure control While all facilities (100%) operated bank accounts, their control over these funds was minimal (Table 4 ). All seven facilities (100%) required external approval from county health administration to spend funds from their accounts. Consequently, only two facilities (28.6%) perceived themselves as having any degree of spending autonomy. These centralized approval requirements caused operational delays. A majority of facilities (57.1%, n = 4) reported that the authorization process typically took 3–4 weeks, while for others delays extended to 2–3 months (28.6%, n = 2) or even beyond three months (14.3%, n = 1). Table 4 Financial autonomy and expenditure control indicators (N = 7) Indicator Number (n) % A. Financial Autonomy Indicators Facilities with a bank account 7 100 Requires external approval to spend funds 7 100 Report moderate-high perceived spending autonomy** 2 28.6 Has formal financial autonomy* 0 0.0 B. Average Timeframe for Spending Authorization 0 3–4 Weeks 4 57.1 2–3 Months 2 28.6 More than 3 Months 1 14.3 *Formal financial autonomy = legal authority to authorize expenditures without external approval **Perceived autonomy = in-charges' subjective sense of control over resource use decisions ***Based on n = 7; all facilities require authorization Two in-charges reporting moderate perceived autonomy felt they could request and sometimes influence specific expenditure decisions through advocacy to county officials, even though final approval rested with the county. This contrasted with other in-charges who felt they had no meaningful input into spending decisions: "At least we can request what we need and sometimes they listen, especially for urgent things. But it's their decision in the end." (In-charge, Level 4 facility) All in-charges reported that even funds generated locally were deposited in county-controlled accounts and could not be used without authorization.: "The money collected through paybill goes to county and then sent to our account, but I can't use it. I have to be authorized to use it, which can take weeks." (In-charge, Level 4 facility) "We are just custodians of the money. The county controls everything. We have to request and wait, even for small amounts." (In-charge, Level 2 facility) "Even money we generate ourselves through user fees, we can't touch without approval. It doesn't make sense—we know what we need here." (In-charge, Level 3 facility) All in-charges emphasized that authorization delays created cascading operational problems: "The county sometimes waits for other budgets and this makes them take longer to authorize the money. We don't have direct withdrawal, so we just wait." (In-charge, Level 2 facility) "By the time approval comes, the situation has changed. Maybe the patient already went elsewhere or we lost the supplier's quote because prices changed." (In-charge, Level 3 facility) "Three weeks minimum if you're lucky, but it can go to months. For urgent needs like medicines when KEMSA fails, this is impossible." (In-charge, Level 4 facility) Most in-charges (6/7) specifically linked this lack of financial autonomy to their inability to respond to supply chain failures: "When KEMSA doesn't supply and we need to buy locally, we can't act fast. We have to wait for county approval and by then there's a stockout." (In-charge, Level 2 facility) "If we had even small petty cash for emergencies, we could buy locally when there are gaps. But we can't do anything without approval, so patients suffer." (In-charge, Level 3 facility) Several in-charges (4/7) explicitly noted the contradiction between this financial recentralization and devolution's stated principles. They explained that the recentralization of financial authority the process by which decision-making power that had been devolved to facility level under the Health Sector Services Fund (HSSF) was subsequently pulled back to county level following implementation of the 2012 PFM Act, inconsistent with devolution’s goals. "Devolution was supposed to give us power to decide locally and respond to our community's needs, but now we have less control than before the HSSF days." (In-charge, Level 4 facility) "They say devolution brings services closer to people, but the money and the power to use it is further away than ever. Everything must go through county offices." (In-charge, Level 2 facility) Effects of financing mechanisms on NCD service delivery The combined effects of limited funding sources, weak NCD budgeting, and restricted financial autonomy were reflected in frequent medication stockouts (Table 5 ). A majority of facilities (85.7%, n = 6) experienced frequent or very frequent stockouts of essential hypertension and diabetes medicines, with 42.9% (n = 3) reporting stockouts occurring almost always and another 42.9% experiencing stockouts more than four times annually (Table 5 ). Only one facility (14.3%) reported merely occasional stockouts (3–4 times per year). Table 5 Service readiness and medication availability indicators (N = 7) Indicator Number (n) Percentage (%) A. Service Readiness Facilities with NCD-trained staff 3 42.9 Facilities with adequate NCD equipment 3 42.9 B. Medication Availability 0 Reports frequent or very frequent medication stockouts 6 85.7 Very frequently (almost always) 3 42.9 Frequently (more than 4 times per year) 3 42.9 Occasionally (3–4 times per year) 1 14.3 In-charges linked these shortages to unreliable central supplies and inability to procure locally: "Inconsistent supplies from both the county warehouses and KEMSA [Kenya Medical Supplies Authority], plus inadequate finance to make local arrangements for the drugs when there are gaps." (Facility in-charge, Level 2 facility) "KEMSA is supposed to supply us, but they stockout too or delay. We should be able to buy locally to fill the gap, but we can't because we need county approval and that takes weeks." (In-charge, Level 3 facility) The lack of financial autonomy meant facilities could not procure medicines locally to bridge gaps when central supplies failed, unlike facilities in systems with greater autonomy. In-charges explicitly linked this cascade of financial failures from inadequate funding to delayed authorization to medication unavailability to substantial consequences across multiple domains. Clinical outcomes and patient safety. All in-charges reported that medication stockouts directly led to disease progression and preventable complications. They described patients presenting with uncontrolled hypertension or diabetes because they could not access medications: "The moment that there are no drugs there are complications because patients can't afford to buy drugs elsewhere. Some try to manage without, which is dangerous." (In-charge, Level 2 facility) "We see patients deteriorating because of stockouts. They come back with strokes, kidney problems, or diabetic complications that could have been prevented if we had consistent drug supply." (In-charge, Level 4 facility) "[There is] no effective diagnosis and monitoring when equipment breaks down and also misdiagnosis because equipment are faulty but we can't get them fixed without approval for funds." (In-charge, Level 2 facility) Patient trust and continuity of care. All in-charges emphasized that persistent service failures eroded patient confidence in the public health system, leading to treatment abandonment and loss to follow-up: "When patients come here repeatedly and we have no medicine, they lose faith in us. They stop coming for their appointments, which leads to poor adherence and worse outcomes. We see them later with complications." (In-charge, Level 4 facility) "Stockouts and delay in services because of financing problems—clients run away because of these. They go to private facilities or just stop treatment." (In-charge, Level 3 facility) "Once you disappoint a patient several times, they don't come back. Then we lose them until they have an emergency. That's not how chronic disease care should work." (In-charge, Level 2 facility) Staff morale and operational capacity. Most in-charges (6/7) described how financial constraints placed immense strain on health workers, who possessed clinical skills but lacked the resources to apply them effectively: "It is demoralizing. You have the skills and training, but you cannot offer the service because there are no medicines or the glucometer has no strips. That's very frustrating for a professional." (In-charge, Level 2 facility) "We have staff who are overworked and burnt out, and at the same time, we cannot even find funds for basic things like batteries for the BP machines or glucometer strips. It becomes a constant struggle that affects morale." (In-charge, Level 2 facility) "Our nurses and clinical officers feel helpless when they can't help patients because of system failures beyond our control. Some are considering leaving for facilities where they can actually practice." (In-charge, Level 4 facility) Discussion This study examined financial determinants affecting hypertension and diabetes management in rural primary health care (PHC) facilities within Kenya’s devolved health system. Several key insights emerge. First, although all facilities prepared annual workplans and budgets, none achieved comprehensive NCD-specific planning with dedicated budget lines. Facility in-charges described the process as largely procedural, producing documents that fulfilled administrative requirements but were disconnected from actual resource flows. This pattern, described by participants as “ritual planning,” mirrors prior research showing fragmentation between planning and budgeting in devolved Kenyan counties [ 14 , 30 ]. The absence of ring-fenced NCD budget lines undermines prioritization of chronic care—an issue also reported across sub-Saharan Africa, where acute and donor-funded programs routinely outcompete NCDs for limited funds [ 34 – 37 ]. Second, facilities relied heavily on narrow and unstable funding sources, primarily NHIF reimbursements and donor support from Danida. Over half depended on two or fewer sources, leaving them financially vulnerable. Facility in-charges consistently cited delays of two to four months in NHIF reimbursements, while donor funds were considered unpredictable. These findings reinforce evidence that NCDs receive less than 2% of global development assistance for health [ 36 ] and that reliance on external partners constrains sustainability. As Kenya transitions to the Social Health Authority (SHA) framework, the findings highlight design priorities: payment rates should reflect actual NCD service costs, reimbursement must be timely, and county governments should complement insurance reimbursements with predictable domestic allocations [ 9 ]. Third, the study confirms that delays and unpredictability in fund disbursement—both from county budgets and insurance reimbursements—directly disrupt service delivery. The high prevalence of medication stockouts (85.7% of facilities) represents the most visible outcome of these systemic weaknesses. In-charges attributed stockouts to the combination of unreliable central supplies and lack of financial flexibility to procure locally. Similar findings elsewhere in Kenya and other LMICs link financing delays to poor treatment adherence, increased preventable complications, and erosion of patient trust [ 9 , 12 , 16 , 38 , 39 ]. Fourth, while devolution was intended to enhance local decision-making, all facilities reported limited financial autonomy. Expenditures required county-level authorization, often taking weeks or months. This effective recentralization of financial authority contradicts the autonomy envisioned in the 2010 Constitution. Although the Public Finance Management Act (2012) sought to strengthen accountability, its implementation restricted local decision space, reversing earlier flexibility under the Health Sector Services Fund (HSSF) [ 14 , 40 , 41 ]. Consistent with international evidence, such centralization diminishes facility responsiveness, particularly for chronic care requiring continuous medicine availability [ 42 , 43 ]. Some counties have adopted by-laws allowing limited “spend-at-source” provisions, suggesting that greater autonomy is achievable within existing legal frameworks if supported politically and administratively. Fifth, qualitative accounts indicated that recurrent expenditures, particularly wages for casual workers, utilities, and operational costs dominated facility budgets, leaving minimal resources for NCD commodities and equipment. This mirrors national trends where operational obligations crowd out service delivery investment. For chronic care, where consistent drug supply and patient follow-up are essential, this imbalance reduces both efficiency and quality. The interaction of inadequate funding, lack of NCD budget lines, and constrained autonomy creates a structural “triple constraint” that perpetuates weak chronic disease management at PHC level. Finally, a few in-charges from higher-level facilities described partial success in advocating for resources through evidence-based budgeting and data-driven justification, reflecting how leadership and engagement can mitigate but not eliminate systemic constraints. Such isolated experiences illustrate that individual managerial capacity can moderate the effects of institutional barriers but cannot substitute for structural reforms that ensure predictable, autonomous, and equitable financing. Overall, the findings reveal that Kenya’s devolved health-financing architecture has yet to operationalize the principles of effectiveness, efficiency, and equity articulated in the Kenya Health Financing Strategy (2020–2030). Strengthening financial autonomy, ensuring timely fund disbursement, and establishing ring-fenced NCD allocations are critical to achieving effective and equitable NCD service delivery under the country’s Universal Health Coverage (UHC) agenda. Conclusion A key limitation of this study is the small sample size of seven facilities in one sub-county, which limits statistical generalizability to Kenya's other 46 counties that vary substantially in governance capacity, resource availability, and health system prioritization. Our findings reflect the specific political economy and administrative culture of Kisumu County and may not fully represent conditions elsewhere, though the systemic issues identified; tensions between centralized control and operational autonomy, NCD under-prioritization, and cascading financing failures, are structural features of Kenya's devolved health system likely prevalent across counties. The cross-sectional design captured a single time point, precluding causal attribution in the strict epidemiological sense or analysis of temporal trends. Additionally, the study was conducted under the NHIF system prior to SHA implementation; Kenya's financing architecture is evolving, and future research should examine whether SHA addresses the financing gaps and autonomy constraints documented here. Despite these limitations, the mixed-methods approach combining quantitative financial data with qualitative insights from facility in-charges provides valuable evidence on mechanisms through which financing arrangements constrain NCD service delivery. Several recommendations for policy can be drawn from our findings. First, county governments must transition from procedural compliance to meaningful strategic planning for NCD services. This requires establishing mandatory ring-fenced NCD budget lines in county and facility budgets, proportionate to disease burden as documented in routine health information systems. Formulaic allocation criteria should ensure facilities receive predictable NCD funding, with accountability mechanisms linking county-level budget execution to facility-level service delivery outcomes. Second, counties must grant primary health care facilities greater financial autonomy with appropriate accountability mechanisms. This could include establishing facility-level revolving funds with pre-authorized spending limits for emergency procurement, implementing digital authorization systems reducing approval timeframes from weeks to days, and adopting performance-based contracts granting facilities autonomy proportionate to demonstrated management capacity. The fact that some counties already provide such autonomy demonstrates feasibility within the current legislative environment; what is needed is political will and technical guidance from the national Ministry of Health. Third, both national and county governments must work to diversify and strengthen funding sources for NCD care, transitioning away from heavy reliance on volatile donor support and delayed insurance reimbursements. As Kenya implements the Social Health Authority, policymakers must ensure that provider payment mechanisms for NCD services are adequate, timely, and predictable, with reimbursement processing substantially faster than the 2–4 month NHIF delays documented. Counties should complement insurance mechanisms with direct, predictable budget allocations from county equitable share allocations and locally generated revenues. Fourth, immediate interventions to address medication stockouts are critical. Establishing small, facility-level emergency procurement funds pre-authorized for use when central supply systems fail could substantially mitigate stockout frequency and duration even before broader financing reforms mature. Finally, county governments should assess health facility resource needs systematically to determine appropriate levels of financing for public health facilities. Such assessments should explicitly quantify NCD service costs including medications, diagnostics, and personnel time, generating evidence to guide appropriate resource allocation during budget negotiations. Without such data-driven approaches, NCDs will continue to be chronically underfunded as they compete with more visible, acute health needs. The promise of devolution, bringing decision-making and resources closer to communities to enhance responsiveness, can only be realized if primary health care facilities receive adequate, predictable funding and sufficient autonomy to deploy resources effectively in meeting the growing burden of noncommunicable diseases. Abbreviations BMC BioMed Central BP Blood Pressure CHMTs County Health Management Teams CHUs Community Health Units DM Diabetes Mellitus FIF Facility Improvement Fund GDP Gross Domestic Product HSSF Health Sector Services Fund HTN Hypertension JOOUST Jaramogi Oginga Odinga University of Science and Technology KEPH Kenya Essential Package for Health KEMSA Kenya Medical Supplies Authority KES Kenyan Shillings LMICs Low- and Middle-Income Countries MCP Model Care Provider (or remove if not used) NACOSTI National Commission for Science, Technology and Innovation NCDs Noncommunicable Diseases NGO Non-Governmental Organization NHIF National Hospital Insurance Fund PCNs Primary Care Networks PEN Package of Essential Noncommunicable Disease Interventions PFM Public Finance Management PHC Primary Health Care SHA Social Health Authority TB Tuberculosis UHC Universal Health Coverage USD United States Dollar VLIR-UOS Flemish Interuniversity Council - University Development Cooperation WHO World Health Organization Declarations Ethics approval and consent to participate This study received ethics approval from the Jaramogi Oginga Odinga University of Science and Technology (JOOUST) Ethics Review Committee (Approval No: ERC 16/01/23) and a research license from the National Commission for Science, Technology and Innovation (NACOSTI) (License No: NACOSTI/P/25/414763). Permission was obtained from the Kisumu County Department of Health and Seme Sub-County Health Management Team. Written informed consent was obtained from all participants after explaining the study's purpose, voluntary nature of participation, confidentiality measures, and right to withdraw without consequences. All data were anonymized and reported in aggregated form to protect participant identity. Electronic data and audio files were stored on password-protected computers accessible only to the research team. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during this study are not publicly available due to confidentiality agreements with participating health facilities and ethical restrictions related to potentially identifiable facility-level financial data. However, anonymized datasets are available from the corresponding author on reasonable request and with appropriate ethical approval. The data collection instruments (structured questionnaire and semi-structured interview guide) used in this study are provided as Additional File 1 Competing interests The authors declare that they have no competing interests. Funding This study was conducted as part of the VLIR-UOS+JOOUST SP3 Project. The funder had no role in study design, data collection, analysis, interpretation, or manuscript preparation. Authors' contributions NWA conceptualized the study, designed the methodology and data collection tools, conducted all field data collection and facility visits, performed quantitative and qualitative data analysis, and drafted the initial manuscript. JO contributed to study conceptualization, supervised data collection activities, and provided critical review of analysis and manuscript drafts. EM and JAO contributed to data collection tool development, participated in qualitative data collection, and reviewed manuscript drafts. DOA and DO provided supervisory oversight, contributed to study design, reviewed analysis outputs, and provided critical revision of manuscript drafts. All authors read and approved the final manuscript. Acknowledgements We thank the Kisumu County Department of Health and Seme Sub-County Health Management Team for facilitating this research. We are grateful to all health facility in-charges who participated in this study. 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1","display":"","copyAsset":false,"role":"figure","size":179087,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual Framework Illustrating the Influence of Financial Mechanisms and Contextual Factors on Hypertension and Diabetes Care Effectiveness in Public PHC Facilities, Seme Subcounty.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8079392/v1/d5db5f1a520ee037dbbb5c5b.jpg"},{"id":104739651,"identity":"3c7b30bf-4ffb-41bf-abc7-cfc559afaea7","added_by":"auto","created_at":"2026-03-16 16:11:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1351461,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8079392/v1/63dd5aa0-223d-4815-899e-8e62ef892db4.pdf"},{"id":97138652,"identity":"4a6d89f4-9617-42cd-b318-f554849298a1","added_by":"auto","created_at":"2025-12-01 09:59:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":35478,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8079392/v1/94e63b667c859bd8878d7ff7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Financial Determinants of Effective Hypertension and Diabetes Care in Rural Primary Health Facilities in Kisumu, Kenya: A Mixed-Methods Study","fulltext":[{"header":"Background","content":"\u003cp\u003eNoncommunicable diseases (NCDs) constitute a rapidly escalating public health crisis in sub-Saharan Africa, with hypertension and diabetes representing particularly urgent challenges. Globally, NCDs account for over 70% of all deaths, disproportionately affecting low- and middle-income countries (LMICs) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Kenya, NCDs have surpassed communicable diseases as the leading cause of mortality, with cardiovascular diseases responsible for over 27% of all deaths [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. National surveys indicate that approximately 26% of adults have elevated blood pressure and 5.6% have raised blood glucose levels [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], creating a substantial and growing demand for chronic disease management services.\u003c/p\u003e\u003cp\u003eEffective management of hypertension and diabetes requires sustained access to screening, diagnosis, treatment, and long-term monitoring with affordable medicines [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Delivering these services depends critically on adequate and predictable health financing [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this study, effectiveness is operationalized in line with the Kenya Health Financing Strategy (2020\u0026ndash;2030), which identifies effectiveness and efficiency as core strategic principles guiding health-financing reforms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Effectiveness reflects the extent to which financing mechanisms enable facilities to achieve desired health outcomes through: (1) continuous availability of essential medicines and diagnostics; (2) continuity of patient care and follow-up; (3) prevention of severe complications requiring hospitalization; and (4) responsiveness to patient needs. Other guiding principles such as appropriateness, transparency, social solidarity, and equity are evaluated in this study within the context of NCD financing at the primary health-care level.\u003c/p\u003e\u003cp\u003eAccording to the World Health Organization\u0026rsquo;s health-financing framework, the capacity of a health system to deliver quality, accessible services without financial hardship depends on how resources are collected, pooled, and purchased [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In Kenya, health financing occurs through several channels, including government tax-based allocations, social health insurance (previously the National Hospital Insurance Fund [NHIF], replaced in 2024 by the Social Health Authority [SHA]), donor contributions, and out-of-pocket payments. However, the flow and management of these resources at the facility level largely determine service delivery capacity, particularly for chronic conditions that require sustained care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrimary health care (PHC) facilities form the foundation of Kenya\u0026rsquo;s health system under the Kenya Essential Package for Health (KEPH) framework. The framework defines a tiered system of increasing service complexity: Level 1 (community health units) provide health promotion and referral linkages; Level 2 (dispensaries) offer basic outpatient care and NCD screening; Level 3 (health centres) provide expanded outpatient, laboratory, and maternal care; and Level 4 (sub-county hospitals) deliver comprehensive services including inpatient and specialized NCD management. Each successive level requires greater financial and human-resource inputs, with financing expected to align proportionately with function. However, PHC facilities (Levels 2\u0026ndash;4) often operate under resource constraints that limit their ability to provide consistent NCD services [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eKenya\u0026rsquo;s health sector underwent major transformation with the 2010 Constitution and 2013 devolution of governance, which created a two-tier system comprising the national government and 47 semi-autonomous county governments [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Counties assumed responsibility for delivering services at community and primary levels, while the national government retained policy and regulatory oversight [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Devolution was intended to enhance responsiveness, accountability, and efficiency by bringing decision-making and resources closer to populations [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Despite these objectives, devolution has been accompanied by persistent financing challenges: fragmented planning and budgeting processes, delayed and unpredictable fund flows, and wide variation in county prioritization [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although health-sector allocations increased from 6% of the national budget in 2015 to 11% in 2023 [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], these remain below the 15% Abuja target and insufficient to meet the escalating NCD burden.\u003c/p\u003e\u003cp\u003eA pivotal reform shaping health-facility financing was the Public Finance Management (PFM) Act of 2012, which inadvertently recentralized financial authority at county level. Before the Act, the Health Sector Services Fund (HSSF) had enabled facilities to retain and manage revenues locally, enhancing flexibility to procure essential commodities during supply shortages. However, following PFM Act implementation, most counties required all facility funds to pass through county treasuries, with expenditures subject to county-level approval. While designed to improve accountability, this shift reduced operational flexibility, delaying procurement and undermining timely response to medication stockouts or equipment failures, issues critical to chronic disease management [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The ongoing tension between financial accountability and local autonomy remains a central governance challenge within Kenya\u0026rsquo;s devolved health system.\u003c/p\u003e\u003cp\u003eFinancing constraints at the facility level have direct implications for NCD service delivery. Inadequate and unpredictable funding compromises the consistent availability of medicines, diagnostics, and trained personnel, all vital for effective chronic care [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Unlike vertical programs for HIV, TB, and malaria that benefit from earmarked funding, NCD programs lack ring-fenced budget allocations and are integrated into general PHC budgets, leaving them vulnerable to competing priorities. Limited data on NCD burden, cost, and utilization further weaken their case during budgeting cycles [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Consequently, NCD services frequently suffer from chronic underfunding and irregular supplies of essential drugs.\u003c/p\u003e\u003cp\u003eNon-state actors contribute variably to NCD financing at the county level. Development partners such as Danida have supported selected counties, while social health insurance reimbursements through NHIF/SHA offer limited financial protection. However, delays in reimbursements and unpredictable payment amounts continue to destabilize facility operations for chronic disease management [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese systemic financing gaps have significant implications for Universal Health Coverage (UHC) and health equity. Effective UHC requires that all individuals, regardless of socioeconomic or geographic status, have access to quality health services without financial hardship. Yet, the current financing architecture in Kenya\u0026rsquo;s devolved system limits equitable access to essential chronic disease services particularly in rural areas where facilities depend on narrow, unpredictable revenue streams and have limited fiscal autonomy.\u003c/p\u003e\u003cp\u003eDespite multiple financing reforms and the growing burden of NCDs, empirical evidence on how financing mechanisms at the PHC facility level affect hypertension and diabetes service delivery remain limited. Previous studies have addressed health-system financing broadly [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], but have rarely examined facility-level processes or incorporated managerial perspectives. Understanding how revenue sources, budgeting processes, and resource allocation decisions interact to shape service effectiveness is critical for informing equitable health-financing reforms.\u003c/p\u003e\u003cp\u003eKisumu County, in western Kenya, offers a relevant context for this inquiry. The county faces a high prevalence of hypertension and diabetes and is piloting innovations such as Primary Care Networks (PCNs) and eHealth initiatives aimed at strengthening PHC coordination. Within this setting, rural sub-counties like Seme experience the dual challenge of implementing reforms amid limited fiscal capacity and infrastructure. This study therefore investigates how financing arrangements influence effective hypertension and diabetes management in Seme Sub-County\u0026rsquo;s PHC facilities. Specifically, the study aims to: (1) identify sources of funding for NCD management; (2) examine planning and budgeting processes; (3) assess allocation and utilization of financial resources; and (4) analyze how financing mechanisms influence the effectiveness of NCD service delivery. Findings aim to provide actionable evidence to inform Kenya\u0026rsquo;s ongoing pursuit of UHC and strengthen financial resilience within devolved health systems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eWe conducted a convergent parallel mixed-methods cross-sectional study using a multi-site case study approach [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Quantitative and qualitative data were collected concurrently, analyzed separately, and integrated during interpretation to generate complementary insights into facility financing mechanisms. The design was QUAL-dominant at the analytical stage because the small facility sample size (N\u0026thinsp;=\u0026thinsp;7) limited statistical inference, while qualitative data provided essential contextual understanding [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Both data types were, however, equally valued during data collection and interpretation.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in Seme Sub-County, a rural sub-county of Kisumu County, western Kenya. Kisumu was purposively selected due to its high prevalence of hypertension and diabetes and its ongoing implementation of Primary Care Networks (PCNs) and eHealth initiatives aimed at strengthening coordination between community and facility levels. These reforms provided a relevant context for examining facility-level financial mechanisms within a devolved health system.\u003c/p\u003e\u003cp\u003eThis research was nested within the broader VLIR-UOS\u0026thinsp;+\u0026thinsp;JOOUST SP3 Project, which seeks to strengthen NCD service delivery in the Lake Basin region. The VLIR project provided the sampling frame and facilitated access to study sites but did not influence this study\u0026rsquo;s research question, instrument design, data collection, or analysis. Data were collected between January and August 2024, before full implementation of VLIR interventions, providing a baseline on financing mechanisms before system strengthening activities commenced.\u003c/p\u003e\n\u003ch3\u003eStudy population and sampling\u003c/h3\u003e\n\u003cp\u003eThe target population comprised public PHC facilities providing NCD services in Seme Sub-County. In consultation with sub-county health officers, eight facilities were initially identified. Seven facilities ultimately participated in the study after one facility declined due to administrative constraints.\u003c/p\u003e\u003cp\u003eThese seven facilities were purposively sampled based on the following criteria: (1) the facility must be a public entity under county government management; (2) the facility must be actively providing services for both hypertension and diabetes; and (3) the facility management team must be willing to participate. While this sample size is small and precludes statistical generalizability, it represents all major public PHC facilities providing NCD services in the sub-county across all KEPH levels (Levels 2\u0026ndash;4), providing comprehensive local coverage. The facilities exhibit typical characteristics of rural primary health care facilities in western Kenya: government-owned, county-managed, serving predominantly rural populations, and operating under similar policy and financing frameworks. These characteristics enhance transferability of findings to similar rural contexts in Kenya, though variations in county governance capacity and resource availability must be acknowledged.\u003c/p\u003e\u003cp\u003eAt each facility, key informants were purposively selected based on their roles and direct involvement in financial management or NCD service delivery. Primary informants were facility in-charges, who possessed comprehensive knowledge of facility operations, budgeting processes, and service delivery challenges.\u003c/p\u003e\n\u003ch3\u003eConceptual framework\u003c/h3\u003e\n\u003cp\u003eThe study was guided by the World Health Organization (WHO) health financing framework, adapted to the facility level. This framework conceptualizes NCD care effectiveness as influenced by four interrelated financial dimensions[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the conceptual framework guiding this study. The framework posits that NCD care effectiveness is influenced by a cascade of financial determinants organized into four interrelated dimensions: (1) sources of financing (diversity and mix of funding sources including government, user fees, NHIF, Facility Improvement Fund (FIF) - a conditional grant designed to support facility-level infrastructure and operational improvements, donors; reliability and consistency of inflows; share of revenue allocated to NCDs); (2) planning and budgeting (planning processes and NCD inclusion; NCD-specific budgeting and transparency; alignment with NCD burden); (3) resource allocation (predictability of allocations; facility autonomy and flexibility; NCD prioritization in allocation); and (4) financial resource utilization (efficiency of expenditure in procurement and disbursement; accountability and oversight; responsiveness to NCD needs). These dimensions are moderated by health facility characteristics (size, staffing, facility type/KEPH level) and collectively determine the dependent variable: effectiveness of hypertension and diabetes care, measured through availability of essential NCD commodities, access to comprehensive NCD services, quality and continuity of care, and equity in service provision.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData collection occurred between January and August 2024, prior to the full implementation of Kenya's 2023 Social Health Insurance Act (enacted November 2023). At the time of data collection, the National Hospital Insurance Fund (NHIF) remained the primary social health insurance mechanism, though the Social Health Authority (SHA) that replaced NHIF had been legally established and was in early implementation phases. The SHA began full operations in October 2024, after our data collection was complete. All data therefore reflect the financing landscape under the NHIF regime and the transition period to SHA.\u003c/p\u003e\n\u003ch3\u003eQuantitative data collection\u003c/h3\u003e\n\u003cp\u003eQuantitative data were collected using a structured questionnaire adapted from the WHO Package of Essential Noncommunicable Disease Interventions (PEN) framework [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and health facility financing assessment tools applied in similar Kenyan contexts [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The tool was modified to include additional variables specific to financial autonomy, NCD-specific budgeting practices, and resource allocation mechanisms at the primary health care level, reflecting Kenya's devolved health financing architecture and the policy context of county-managed health facilities. Modifications included detailed questions on funding source diversity (NHIF, county allocations, Facility Improvement Fund, donor support, user fees), expenditure approval processes and timelines, medication stockout frequency and causes, and perceived effectiveness of different financing mechanisms for NCD care. The final English version of the questionnaire used in this study is provided as a supplementary file (Additional File 1). The tool captured information on facility characteristics, funding sources, planning and budgeting practices, resource allocation, and NCD service availability. Data were collected using KoboToolbox on tablets, enabling real-time validation.\u003c/p\u003e\u003cp\u003eFinancial information was extracted through retrospective review of records, including bank statements, budget reports, expenditure ledgers, and procurement receipts, from January to August 2024. Structured interviews with facility in-charges were conducted to clarify incomplete records and validate financial data, especially regarding funding sources and fund-approval timeframes.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eQualitative data collection\u003c/h2\u003e\u003cp\u003eQualitative data were collected through in-depth, face-to-face interviews with facility in-charges using a semi-structured interview guide developed for this study (Additional File 1). The guide was informed by the WHO health financing framework [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and health facility financing literature in devolved contexts [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], with questions tailored to explore how financing mechanisms specifically affect NCD service delivery in rural primary health care settings. The interview guide explored: (1) sources and adequacy of funding for NCD services; (2) planning and budgeting processes and the extent to which NCDs are prioritized; (3) challenges in fund access, allocation, and utilization; and (4) the perceived impact of financing mechanisms on NCD service delivery quality and patient outcomes. Interviews were conducted in English (the language of professional health care communication in Kenya), lasted approximately 45\u0026ndash;60 minutes, and were audio-recorded with informed consent. The interview guide used open-ended questions such as \"Can you describe how your facility plans and budgets for NCD services?\" followed by probing questions to explore mechanisms and consequences (e.g., \"How does this affect your ability to manage patients with diabetes?\"). An observation checklist was also used to systematically document the availability and functional status of essential NCD resources, including medications (specifically checking for common antihypertensives and antidiabetics listed in WHO PEN), blood pressure apparatus, glucometers, test strips, and patient registers/management tools.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData management and analysis\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eQuantitative analysis\u003c/h2\u003e\u003cp\u003eQuantitative data were entered and cleaned in Microsoft Excel before being exported to STATA version 16 (StataCorp, College Station, TX, USA) for analysis. Given the small sample size (N\u0026thinsp;=\u0026thinsp;7 facilities), analysis focused on descriptive statistics. Frequencies, percentages, means, and ranges were calculated to summarize facility characteristics, funding sources, planning and budgeting practices, financial autonomy indicators, and NCD service readiness measures. Results were tabulated to facilitate pattern identification and comparison.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eQualitative analysis\u003c/h2\u003e\u003cp\u003eAudio recordings were transcribed verbatim and transcripts were validated against original recordings for accuracy. Transcripts were imported into R software for thematic analysis following Braun and Clarke's approach [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Analysis proceeded iteratively through several stages: familiarization with data through repeated reading; generation of initial codes based on the study's conceptual framework and research questions; collation of codes into candidate themes; review and refinement of themes; and definition and naming of final themes. The qualitative analysis aimed to uncover the mechanisms, contextual factors, and perspectives that explained the quantitative patterns observed. Two researchers independently coded a subset of transcripts to enhance reliability, and discrepancies were resolved through discussion.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eData integration\u003c/h2\u003e\u003cp\u003eFindings from quantitative and qualitative analyses were integrated during the interpretation phase through triangulation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Qualitative themes were used to explain, contextualize, and provide depth to quantitative findings. For instance, quantitative data on medication stockout frequencies were interpreted in conjunction with qualitative explanations from in-charges regarding why stockouts occurred and their perceived consequences. This integration enhanced the validity and comprehensiveness of findings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eValidity and reliability\u003c/h2\u003e\u003cp\u003eTo ensure instrument validity, the questionnaire and interview guide were pre-tested at a health facility outside the study sample. Feedback was used to refine question clarity, structure, and cultural appropriateness. Tools were also reviewed by the research supervisory team, comprising experts in health financing and epidemiology, to ensure content validity. For the qualitative component, reliability was enhanced through consistent use of the interview guide, systematic probing techniques, and audio recording to minimize interviewer bias and data loss.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eFacility characteristics\u003c/h2\u003e\u003cp\u003eSeven primary health care (PHC) facilities participated in the study, all located in rural settings (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Facilities represented a mix of KEPH service levels: two Level 4 sub-county hospitals (28.6%), three Level 3 health centres (42.9%), and two Level 2 dispensaries (28.6%). No Level 1 community units were included because they do not provide clinical NCD care. Most facilities (71.4%, n\u0026thinsp;=\u0026thinsp;5) had at least one staff member trained in NCD management. Although all possessed basic diagnostic equipment for hypertension and diabetes (blood pressure apparatus and glucometers), fewer than half (42.9%, n\u0026thinsp;=\u0026thinsp;3) considered their equipment adequate for patient demand. Only two facilities (28.6%) reported generating internal revenue through user fees for NCD-related services.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of participating primary health care facilities (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacility Level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel 4 (Sub- County Hospital)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel 3 (Health Centre)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel 2 (Dispensary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLocation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNCD Service Readiness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt least one staff member trained in NCDs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHas essential NCD diagnostic equipment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReports equipment as adequate for patient load\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRevenue Generation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGenerates revenue from user fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eSources of facility funding for NCD care\u003c/h2\u003e\u003cp\u003eThe main funding sources were NHIF reimbursements (71.4%, n\u0026thinsp;=\u0026thinsp;5) and Danida support (71.4%, n\u0026thinsp;=\u0026thinsp;5). Only two facilities (28.6%) received direct county government funds through the Facility Improvement Fund (FIF), and an equal number generated user-fee revenue (28.6%). No facility received NGO support other than Danida, and one facility (14.3%) obtained limited assistance from a private foundation (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSources of facility funding for NCD care (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA. Frequency of Funding Sources Mentioned\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNHIF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDanida\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCounty Government / FIF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUser Fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM-PESA Foundation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther NGO Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eB. Diversity of Funding Sources per Facility\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne Source\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTwo Sources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThree or More Sources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote: N\u0026thinsp;=\u0026thinsp;7 facilities. Sources are not mutually exclusive.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMore than half (57.1%, n\u0026thinsp;=\u0026thinsp;4) relied on only two funding sources, while two facilities (28.6%) depended on a single source. Facility in-charges consistently reported that funds were insufficient and not designated for chronic disease management:\u003c/p\u003e\u003cp\u003e\u0026ldquo;There are no designated funds for NCDs; everything goes into one pot.\u0026rdquo; (In-charge, Level 2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;We cannot specifically say this money is for NCDs. It\u0026rsquo;s all pooled for many competing needs.\u0026rdquo; (In-charge, Level 3)\u003c/p\u003e\u003cp\u003eIn-charges from facilities supported by Danida noted that reliance on donor funding created uncertainty, while those receiving NHIF reimbursements cited payment delays of two to four months, limiting planning capacity:\u003c/p\u003e\u003cp\u003e\u0026ldquo;NHIF takes months to reimburse\u0026mdash;sometimes three or four months. How do you plan with that?\u0026rdquo; (In-charge, Level 3)\u003c/p\u003e\u003cp\u003eCounty government support was described as minimal or irregular:\u003c/p\u003e\u003cp\u003e\u0026ldquo;County support is very limited. We depend mainly on what we generate or on NHIF, but even those are unpredictable.\u0026rdquo; (In-charge, Level 4)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePlanning and budgeting for NCD services\u003c/h2\u003e\u003cp\u003eAll seven facilities reported preparing annual workplans and budgets, fulfilling administrative requirements (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, none demonstrated comprehensive NCD-specific planning\u0026mdash;that is, having a workplan, budget, and dedicated budget line for NCDs. However, when probed about NCD-specific planning, significant deficiencies emerged. While a majority (71.4%, n\u0026thinsp;=\u0026thinsp;5) reported considering NCDs in their budgets, not a single facility (0%) achieved what we defined as comprehensive NCD planning having a work plan, a budget, \u003cem\u003eand\u003c/em\u003e specific, dedicated consideration for NCDs within that budget.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePlanning and budgeting practices for NCD services (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlanning \u0026amp; Budgeting Practice\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacilities with annual work plans\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacilities with annual budgets\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacilities that specifically consider NCDs in the budget\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFacilities with comprehensive NCD planning\u003c/b\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e*Defined as having a work plan, a budget, AND specific consideration for NCDs\u003c/h2\u003e\u003cp\u003eThe dominant perspective among in-charges (5/7) characterized the budgeting process as largely futile. Although the county health system nominally operates a \"bottom-up\" participatory budgeting approach, in-charges explained that their carefully prepared budgets were routinely set aside due to insufficient and unrestricted funding flows from the county government. As a result, budgets functioned as aspirational \"wish lists\" rather than operational financial management tools:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We budget but it's not actualized. These are just wish lists because the money is not enough to implement what we plan.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We prepare very detailed budgets with input from all departments, but at the end of the day, you get what is available, not what you budgeted for.\"\u003c/em\u003e (In-charge, Level 3 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The process feels like an exercise in futility sometimes. We spend days preparing budgets that are never followed when the actual allocation comes.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003eAll in-charges emphasized the impossibility of meaningful NCD budgeting given the absence of dedicated NCD budget lines and overall resource scarcity. One in-charge quantified this inadequacy:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"It doesn't [work], because you only budget with the money received from the facility. And the money is usually very inadequate. Sometimes you can even give NCDs 2,000 [Kenyan Shillings, approximately USD 15] for the whole year.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"How do you budget for NCDs when you don't have dedicated funds? You end up just estimating what you might use from the general pot, but there's no guarantee.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003eMost in-charges (6/7) also described limited facility input into final budget decisions despite the participatory process:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"They say it's bottom-up, but our requests rarely make it to the final budget. The county decides what we get based on what's available, not what we need.\"\u003c/em\u003e (In-charge, Level 3 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We participate in making the budget and presenting our needs, but the implementation is done by the county. They don't follow what we proposed.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003eHowever, two in-charges from Level 4 facilities offered a more nuanced perspective. While acknowledging that NCD budgets were inadequate and often not fully actualized, they emphasized that the budget process did allow them to advocate for resources and occasionally influence allocation decisions:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"It's not perfect, and we rarely get what we ask for, but at least we can present what we need. Sometimes we get a portion of what we requested, especially if we justify it well with data.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The budget process gives us a chance to advocate and make our case. Even if we don't get everything, we can push for priority items like NCD medicines and diagnostic equipment.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003eNevertheless, even these in-charges emphasized that unpredictable funding flows meant actual allocations rarely matched budgeted amounts, limiting their ability to plan effectively for NCD service needs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eFinancial autonomy and expenditure control\u003c/h2\u003e\u003cp\u003eWhile all facilities (100%) operated bank accounts, their control over these funds was minimal (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). All seven facilities (100%) required external approval from county health administration to spend funds from their accounts. Consequently, only two facilities (28.6%) perceived themselves as having any degree of spending autonomy. These centralized approval requirements caused operational delays. A majority of facilities (57.1%, n\u0026thinsp;=\u0026thinsp;4) reported that the authorization process typically took 3\u0026ndash;4 weeks, while for others delays extended to 2\u0026ndash;3 months (28.6%, n\u0026thinsp;=\u0026thinsp;2) or even beyond three months (14.3%, n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFinancial autonomy and expenditure control indicators (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA. Financial Autonomy Indicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacilities with a bank account\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRequires external approval to spend funds\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReport moderate-high perceived spending autonomy**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHas formal financial autonomy*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eB. Average Timeframe for Spending Authorization\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u0026ndash;4 Weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;3 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than 3 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Formal financial autonomy\u0026thinsp;=\u0026thinsp;legal authority to authorize expenditures without external approval\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e**Perceived autonomy\u0026thinsp;=\u0026thinsp;in-charges' subjective sense of control over resource use decisions\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e***Based on n\u0026thinsp;=\u0026thinsp;7; all facilities require authorization\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eTwo in-charges reporting moderate perceived autonomy felt they could \u003cem\u003erequest\u003c/em\u003e and sometimes influence specific expenditure decisions through advocacy to county officials, even though final approval rested with the county. This contrasted with other in-charges who felt they had no meaningful input into spending decisions:\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"At least we can request what we need and sometimes they listen, especially for urgent things. But it's their decision in the end.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003eAll in-charges reported that even funds generated locally were deposited in county-controlled accounts and could not be used without authorization.:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The money collected through paybill goes to county and then sent to our account, but I can't use it. I have to be authorized to use it, which can take weeks.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We are just custodians of the money. The county controls everything. We have to request and wait, even for small amounts.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Even money we generate ourselves through user fees, we can't touch without approval. It doesn't make sense\u0026mdash;we know what we need here.\"\u003c/em\u003e (In-charge, Level 3 facility)\u003c/p\u003e\u003cp\u003eAll in-charges emphasized that authorization delays created cascading operational problems:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The county sometimes waits for other budgets and this makes them take longer to authorize the money. We don't have direct withdrawal, so we just wait.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"By the time approval comes, the situation has changed. Maybe the patient already went elsewhere or we lost the supplier's quote because prices changed.\"\u003c/em\u003e (In-charge, Level 3 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Three weeks minimum if you're lucky, but it can go to months. For urgent needs like medicines when KEMSA fails, this is impossible.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003eMost in-charges (6/7) specifically linked this lack of financial autonomy to their inability to respond to supply chain failures:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"When KEMSA doesn't supply and we need to buy locally, we can't act fast. We have to wait for county approval and by then there's a stockout.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"If we had even small petty cash for emergencies, we could buy locally when there are gaps. But we can't do anything without approval, so patients suffer.\"\u003c/em\u003e (In-charge, Level 3 facility)\u003c/p\u003e\u003cp\u003eSeveral in-charges (4/7) explicitly noted the contradiction between this financial recentralization and devolution's stated principles. They explained that the recentralization of financial authority the process by which decision-making power that had been devolved to facility level under the Health Sector Services Fund (HSSF) was subsequently pulled back to county level following implementation of the 2012 PFM Act, inconsistent with devolution\u0026rsquo;s goals.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Devolution was supposed to give us power to decide locally and respond to our community's needs, but now we have less control than before the HSSF days.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"They say devolution brings services closer to people, but the money and the power to use it is further away than ever. Everything must go through county offices.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cb\u003eEffects of financing mechanisms on NCD service delivery\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe combined effects of limited funding sources, weak NCD budgeting, and restricted financial autonomy were reflected in frequent medication stockouts (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). A majority of facilities (85.7%, n\u0026thinsp;=\u0026thinsp;6) experienced frequent or very frequent stockouts of essential hypertension and diabetes medicines, with 42.9% (n\u0026thinsp;=\u0026thinsp;3) reporting stockouts occurring almost always and another 42.9% experiencing stockouts more than four times annually (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Only one facility (14.3%) reported merely occasional stockouts (3\u0026ndash;4 times per year).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eService readiness and medication availability indicators (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA. Service Readiness\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacilities with NCD-trained staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacilities with adequate NCD equipment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eB. Medication Availability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReports frequent or very frequent medication stockouts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eVery frequently (almost always)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFrequently (more than 4 times per year)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOccasionally (3\u0026ndash;4 times per year)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn-charges linked these shortages to unreliable central supplies and inability to procure locally:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Inconsistent supplies from both the county warehouses and KEMSA [Kenya Medical Supplies Authority], plus inadequate finance to make local arrangements for the drugs when there are gaps.\"\u003c/em\u003e (Facility in-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"KEMSA is supposed to supply us, but they stockout too or delay. We should be able to buy locally to fill the gap, but we can't because we need county approval and that takes weeks.\"\u003c/em\u003e (In-charge, Level 3 facility)\u003c/p\u003e\u003cp\u003eThe lack of financial autonomy meant facilities could not procure medicines locally to bridge gaps when central supplies failed, unlike facilities in systems with greater autonomy. In-charges explicitly linked this cascade of financial failures from inadequate funding to delayed authorization to medication unavailability to substantial consequences across multiple domains.\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical outcomes and patient safety.\u003c/b\u003e All in-charges reported that medication stockouts directly led to disease progression and preventable complications. They described patients presenting with uncontrolled hypertension or diabetes because they could not access medications:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The moment that there are no drugs there are complications because patients can't afford to buy drugs elsewhere. Some try to manage without, which is dangerous.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We see patients deteriorating because of stockouts. They come back with strokes, kidney problems, or diabetic complications that could have been prevented if we had consistent drug supply.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"[There is] no effective diagnosis and monitoring when equipment breaks down and also misdiagnosis because equipment are faulty but we can't get them fixed without approval for funds.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient trust and continuity of care.\u003c/b\u003e All in-charges emphasized that persistent service failures eroded patient confidence in the public health system, leading to treatment abandonment and loss to follow-up:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"When patients come here repeatedly and we have no medicine, they lose faith in us. They stop coming for their appointments, which leads to poor adherence and worse outcomes. We see them later with complications.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Stockouts and delay in services because of financing problems\u0026mdash;clients run away because of these. They go to private facilities or just stop treatment.\"\u003c/em\u003e (In-charge, Level 3 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Once you disappoint a patient several times, they don't come back. Then we lose them until they have an emergency. That's not how chronic disease care should work.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cb\u003eStaff morale and operational capacity.\u003c/b\u003e Most in-charges (6/7) described how financial constraints placed immense strain on health workers, who possessed clinical skills but lacked the resources to apply them effectively:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"It is demoralizing. You have the skills and training, but you cannot offer the service because there are no medicines or the glucometer has no strips. That's very frustrating for a professional.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We have staff who are overworked and burnt out, and at the same time, we cannot even find funds for basic things like batteries for the BP machines or glucometer strips. It becomes a constant struggle that affects morale.\"\u003c/em\u003e (In-charge, Level 2 facility)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Our nurses and clinical officers feel helpless when they can't help patients because of system failures beyond our control. Some are considering leaving for facilities where they can actually practice.\"\u003c/em\u003e (In-charge, Level 4 facility)\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined financial determinants affecting hypertension and diabetes management in rural primary health care (PHC) facilities within Kenya\u0026rsquo;s devolved health system. Several key insights emerge.\u003c/p\u003e\u003cp\u003eFirst, although all facilities prepared annual workplans and budgets, none achieved comprehensive NCD-specific planning with dedicated budget lines. Facility in-charges described the process as largely procedural, producing documents that fulfilled administrative requirements but were disconnected from actual resource flows. This pattern, described by participants as \u0026ldquo;ritual planning,\u0026rdquo; mirrors prior research showing fragmentation between planning and budgeting in devolved Kenyan counties [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The absence of ring-fenced NCD budget lines undermines prioritization of chronic care\u0026mdash;an issue also reported across sub-Saharan Africa, where acute and donor-funded programs routinely outcompete NCDs for limited funds [\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSecond, facilities relied heavily on narrow and unstable funding sources, primarily NHIF reimbursements and donor support from Danida. Over half depended on two or fewer sources, leaving them financially vulnerable. Facility in-charges consistently cited delays of two to four months in NHIF reimbursements, while donor funds were considered unpredictable. These findings reinforce evidence that NCDs receive less than 2% of global development assistance for health [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and that reliance on external partners constrains sustainability. As Kenya transitions to the Social Health Authority (SHA) framework, the findings highlight design priorities: payment rates should reflect actual NCD service costs, reimbursement must be timely, and county governments should complement insurance reimbursements with predictable domestic allocations [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThird, the study confirms that delays and unpredictability in fund disbursement\u0026mdash;both from county budgets and insurance reimbursements\u0026mdash;directly disrupt service delivery. The high prevalence of medication stockouts (85.7% of facilities) represents the most visible outcome of these systemic weaknesses. In-charges attributed stockouts to the combination of unreliable central supplies and lack of financial flexibility to procure locally. Similar findings elsewhere in Kenya and other LMICs link financing delays to poor treatment adherence, increased preventable complications, and erosion of patient trust [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFourth, while devolution was intended to enhance local decision-making, all facilities reported limited financial autonomy. Expenditures required county-level authorization, often taking weeks or months. This effective recentralization of financial authority contradicts the autonomy envisioned in the 2010 Constitution. Although the Public Finance Management Act (2012) sought to strengthen accountability, its implementation restricted local decision space, reversing earlier flexibility under the Health Sector Services Fund (HSSF) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Consistent with international evidence, such centralization diminishes facility responsiveness, particularly for chronic care requiring continuous medicine availability [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Some counties have adopted by-laws allowing limited \u0026ldquo;spend-at-source\u0026rdquo; provisions, suggesting that greater autonomy is achievable within existing legal frameworks if supported politically and administratively.\u003c/p\u003e\u003cp\u003eFifth, qualitative accounts indicated that recurrent expenditures, particularly wages for casual workers, utilities, and operational costs dominated facility budgets, leaving minimal resources for NCD commodities and equipment. This mirrors national trends where operational obligations crowd out service delivery investment. For chronic care, where consistent drug supply and patient follow-up are essential, this imbalance reduces both efficiency and quality. The interaction of inadequate funding, lack of NCD budget lines, and constrained autonomy creates a structural \u0026ldquo;triple constraint\u0026rdquo; that perpetuates weak chronic disease management at PHC level.\u003c/p\u003e\u003cp\u003eFinally, a few in-charges from higher-level facilities described partial success in advocating for resources through evidence-based budgeting and data-driven justification, reflecting how leadership and engagement can mitigate but not eliminate systemic constraints. Such isolated experiences illustrate that individual managerial capacity can moderate the effects of institutional barriers but cannot substitute for structural reforms that ensure predictable, autonomous, and equitable financing.\u003c/p\u003e\u003cp\u003eOverall, the findings reveal that Kenya\u0026rsquo;s devolved health-financing architecture has yet to operationalize the principles of effectiveness, efficiency, and equity articulated in the Kenya Health Financing Strategy (2020\u0026ndash;2030). Strengthening financial autonomy, ensuring timely fund disbursement, and establishing ring-fenced NCD allocations are critical to achieving effective and equitable NCD service delivery under the country\u0026rsquo;s Universal Health Coverage (UHC) agenda.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA key limitation of this study is the small sample size of seven facilities in one sub-county, which limits statistical generalizability to Kenya's other 46 counties that vary substantially in governance capacity, resource availability, and health system prioritization. Our findings reflect the specific political economy and administrative culture of Kisumu County and may not fully represent conditions elsewhere, though the systemic issues identified; tensions between centralized control and operational autonomy, NCD under-prioritization, and cascading financing failures, are structural features of Kenya's devolved health system likely prevalent across counties. The cross-sectional design captured a single time point, precluding causal attribution in the strict epidemiological sense or analysis of temporal trends. Additionally, the study was conducted under the NHIF system prior to SHA implementation; Kenya's financing architecture is evolving, and future research should examine whether SHA addresses the financing gaps and autonomy constraints documented here. Despite these limitations, the mixed-methods approach combining quantitative financial data with qualitative insights from facility in-charges provides valuable evidence on mechanisms through which financing arrangements constrain NCD service delivery.\u003c/p\u003e\u003cp\u003eSeveral recommendations for policy can be drawn from our findings. First, county governments must transition from procedural compliance to meaningful strategic planning for NCD services. This requires establishing mandatory ring-fenced NCD budget lines in county and facility budgets, proportionate to disease burden as documented in routine health information systems. Formulaic allocation criteria should ensure facilities receive predictable NCD funding, with accountability mechanisms linking county-level budget execution to facility-level service delivery outcomes. Second, counties must grant primary health care facilities greater financial autonomy with appropriate accountability mechanisms. This could include establishing facility-level revolving funds with pre-authorized spending limits for emergency procurement, implementing digital authorization systems reducing approval timeframes from weeks to days, and adopting performance-based contracts granting facilities autonomy proportionate to demonstrated management capacity. The fact that some counties already provide such autonomy demonstrates feasibility within the current legislative environment; what is needed is political will and technical guidance from the national Ministry of Health. Third, both national and county governments must work to diversify and strengthen funding sources for NCD care, transitioning away from heavy reliance on volatile donor support and delayed insurance reimbursements. As Kenya implements the Social Health Authority, policymakers must ensure that provider payment mechanisms for NCD services are adequate, timely, and predictable, with reimbursement processing substantially faster than the 2\u0026ndash;4 month NHIF delays documented. Counties should complement insurance mechanisms with direct, predictable budget allocations from county equitable share allocations and locally generated revenues. Fourth, immediate interventions to address medication stockouts are critical. Establishing small, facility-level emergency procurement funds pre-authorized for use when central supply systems fail could substantially mitigate stockout frequency and duration even before broader financing reforms mature. Finally, county governments should assess health facility resource needs systematically to determine appropriate levels of financing for public health facilities. Such assessments should explicitly quantify NCD service costs including medications, diagnostics, and personnel time, generating evidence to guide appropriate resource allocation during budget negotiations. Without such data-driven approaches, NCDs will continue to be chronically underfunded as they compete with more visible, acute health needs. The promise of devolution, bringing decision-making and resources closer to communities to enhance responsiveness, can only be realized if primary health care facilities receive adequate, predictable funding and sufficient autonomy to deploy resources effectively in meeting the growing burden of noncommunicable diseases.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBioMed Central\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBlood Pressure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHMTs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCounty Health Management Teams\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHUs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommunity Health Units\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiabetes Mellitus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFIF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFacility Improvement Fund\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGDP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGross Domestic Product\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHSSF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Sector Services Fund\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHTN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eJOOUST\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eJaramogi Oginga Odinga University of Science and Technology\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKEPH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKenya Essential Package for Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKEMSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKenya Medical Supplies Authority\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKES\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKenyan Shillings\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMCP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eModel Care Provider (or remove if not used)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNACOSTI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Commission for Science, Technology and Innovation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNCDs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNoncommunicable Diseases\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNGO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon-Governmental Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNHIF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Hospital Insurance Fund\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCNs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary Care Networks\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePEN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePackage of Essential Noncommunicable Disease Interventions\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePFM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePublic Finance Management\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary Health Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSocial Health Authority\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTuberculosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUniversal Health Coverage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States Dollar\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVLIR-UOS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFlemish Interuniversity Council - University Development Cooperation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethics approval from the Jaramogi Oginga Odinga University of Science and Technology (JOOUST) Ethics Review Committee (Approval No: ERC 16/01/23) and a research license from the National Commission for Science, Technology and Innovation (NACOSTI) (License No: NACOSTI/P/25/414763). Permission was obtained from the Kisumu County Department of Health and Seme Sub-County Health Management Team. Written informed consent was obtained from all participants after explaining the study\u0026apos;s purpose, voluntary nature of participation, confidentiality measures, and right to withdraw without consequences. All data were anonymized and reported in aggregated form to protect participant identity. Electronic data and audio files were stored on password-protected computers accessible only to the research team.\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during this study are not publicly available due to confidentiality agreements with participating health facilities and ethical restrictions related to potentially identifiable facility-level financial data. However, anonymized datasets are available from the corresponding author on reasonable request and with appropriate ethical approval.\u003c/p\u003e\n\u003cp\u003eThe data collection instruments (structured questionnaire and semi-structured interview guide) used in this study are provided as Additional File 1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted as part of the VLIR-UOS+JOOUST SP3 Project. The funder had no role in study design, data collection, analysis, interpretation, or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNWA conceptualized the study, designed the methodology and data collection tools, conducted all field data collection and facility visits, performed quantitative and qualitative data analysis, and drafted the initial manuscript. JO contributed to study conceptualization, supervised data collection activities, and provided critical review of analysis and manuscript drafts. EM and JAO contributed to data collection tool development, participated in qualitative data collection, and reviewed manuscript drafts. DOA and DO provided supervisory oversight, contributed to study design, reviewed analysis outputs, and provided critical revision of manuscript drafts. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the Kisumu County Department of Health and Seme Sub-County Health Management Team for facilitating this research. We are grateful to all health facility in-charges who participated in this study. We acknowledge the VLIR-UOS SP3 Project for supporting this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEzzati M, Pearson-Stuttard J, Bennett JE, Mathers CD. Acting on non-communicable diseases in low-and middle-income tropical countries. Nature. 2018;559(7715):507\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVos T et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019, \u003cem\u003eThe lancet\u003c/em\u003e, vol. 396, no. 10258, pp. 1204\u0026ndash;1222, 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoH, Ministry of Health. Kenya National Strategy for the Prevention and control of non-communicable diseases. Kenya National Strategy; 2015.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWamai RG, Kengne AP, Levitt N. Non-communicable diseases surveillance: overview of magnitude and determinants in Kenya from STEPwise approach survey of 2015. BMC Public Health. 2018;18:1224. Suppl 3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings. 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Oct. 2016;16(6):561. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-016-1784-9\u003c/span\u003e\u003cspan address=\"10.1186/s12913-016-1784-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health financing, Primary health care, Noncommunicable diseases, Hypertension, Diabetes, Devolution, Kenya, Financial autonomy, Medication stockouts","lastPublishedDoi":"10.21203/rs.3.rs-8079392/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8079392/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eNoncommunicable diseases (NCDs), particularly hypertension and diabetes, account for 27% of deaths in Kenya, with 26% of adults having elevated blood pressure. Despite devolution of health services to county governments in 2013, financing for NCD management at the primary health care (PHC) level remains weak. This study examines financial determinants shaping hypertension and diabetes care in PHC facilities within a devolved county health system in rural Kisumu County, Kenya.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a convergent parallel mixed-methods cross-sectional study in seven public PHC facilities in Seme Sub-County. Quantitative data were collected via structured questionnaires and retrospective document review of financial records (January\u0026ndash;August 2024). Qualitative data were gathered through in-depth interviews with facility in-charges exploring planning, budgeting, and resource allocation. Descriptive statistics were produced in STATA v16; qualitative data were analyzed thematically in R.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll seven facilities prepared annual workplans and budgets, but none achieved comprehensive NCD-specific planning (workplan\u0026thinsp;+\u0026thinsp;budget\u0026thinsp;+\u0026thinsp;dedicated NCD budget line). Funding sources were narrow: 71.4% (n\u0026thinsp;=\u0026thinsp;5) depended on NHIF reimbursements and donor support, while only 28.6% (n\u0026thinsp;=\u0026thinsp;2) received direct county funding; 57.1% (n\u0026thinsp;=\u0026thinsp;4) relied on only two funding streams. Although all facilities held bank accounts, none had formal financial autonomy and expenditures required county-level approval, typically taking 3\u0026ndash;4 weeks (57.1%, n\u0026thinsp;=\u0026thinsp;4) to over two months (28.6%, n\u0026thinsp;=\u0026thinsp;2). Combined with unreliable central supplies, this lack of autonomy meant facilities could not procure locally when stockouts occurred; consequently 85.7% (n\u0026thinsp;=\u0026thinsp;6) reported frequent medication stockouts. Facility in-charges attributed these failures to inadequate, unpredictable funding and centralized approval processes that prevented timely local procurement.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ePHC facilities in this rural county operate under severely constrained financial conditions that undermine effective NCD care. Strengthening facility financial autonomy, instituting ring-fenced NCD budget lines, diversifying financing, and streamlining disbursement and emergency procurement mechanisms are urgent priorities to reduce stockouts and advance equitable chronic care under Kenya\u0026rsquo;s UHC agenda.\u003c/p\u003e","manuscriptTitle":"Financial Determinants of Effective Hypertension and Diabetes Care in Rural Primary Health Facilities in Kisumu, Kenya: A Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-28 09:28:26","doi":"10.21203/rs.3.rs-8079392/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-12T09:22:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-06T11:18:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227018924788666183100293350568817811141","date":"2026-01-06T09:52:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95905037232622151223529657661101282209","date":"2026-01-02T09:40:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-01T21:45:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283156374963815888302488564361447840923","date":"2025-12-04T23:52:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283048467155246816964037083940319565713","date":"2025-11-26T06:40:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-23T23:24:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-23T23:14:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-17T04:18:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-16T11:14:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-16T11:11:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1ea791ca-1a81-4c68-9736-21bb21ae9348","owner":[],"postedDate":"November 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:06:49+00:00","versionOfRecord":{"articleIdentity":"rs-8079392","link":"https://doi.org/10.1186/s12889-026-26963-8","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-03-11 16:00:20","publishedOnDateReadable":"March 11th, 2026"},"versionCreatedAt":"2025-11-28 09:28:26","video":"","vorDoi":"10.1186/s12889-026-26963-8","vorDoiUrl":"https://doi.org/10.1186/s12889-026-26963-8","workflowStages":[]},"version":"v1","identity":"rs-8079392","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8079392","identity":"rs-8079392","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}