Building budgeting capacity of Health Facility Managers to enhance facility financial autonomy: lessons from Nakuru county, Kenya.

Building budgeting capacity of Health Facility Managers to enhance facility financial autonomy: lessons from Nakuru county, Kenya | medRxiv Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Building budgeting capacity of Health Facility Managers to enhance facility financial autonomy: lessons from Nakuru county, Kenya Harrison Ochieng , Fionah Macharia , Joy Mugambi , Peter Nguhiu , Sally Ndungu , Caren Nekesa , Tatiana Ogola , Dennis Amunga , Georges Simiyu , Nelson Kamanda , Wanjiku Chege , Patrick Mwaura , Newton Angwa , Wangari Ng‘ang‘a , Mike Mulongo , Edwine Barasa doi: https://doi.org/10.64898/2026.03.18.26348677 Harrison Ochieng 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: harrisonochieng47{at}gmail.com Fionah Macharia 2 County Department of Health , Nakuru County, Nakuru, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Joy Mugambi 2 County Department of Health , Nakuru County, Nakuru, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Peter Nguhiu 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sally Ndungu 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Caren Nekesa 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Tatiana Ogola 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Dennis Amunga 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Georges Simiyu 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Nelson Kamanda 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Wanjiku Chege 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Patrick Mwaura 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Newton Angwa 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Wangari Ng‘ang‘a 3 Gates Foundation , Seattle, United States of America ( USA ) Find this author on Google Scholar Find this author on PubMed Search for this author on this site Mike Mulongo 1 Hecta Consulting Limited , Nairobi, Kenya Find this author on Google Scholar Find this author on PubMed Search for this author on this site Edwine Barasa 4 Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme , Nairobi, Kenya 5 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford , Oxford, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Background Health facility financial autonomy enables facilities to retain their revenue and use it to meet facility level needs and priorities to ensure responsiveness, accountability and efficiency. Public facilities need to develop public finance management (PFM) compliant budgets before spending this revenue. However, existing constraints such as lack of competencies and capacities among facility managers in developing budgets and limited political goodwill have influenced the existence of autonomy. This study presents a case study of Nakuru county which implemented an intervention to enhance the capacity of facility managers in developing, implementing and monitoring budgets. Methods We used a qualitative case study approach, with data collected through participant observations and document analysis. We utilized process evaluation in examining the motivations for the intervention, its implementation, early outcomes and the role of context in these outcomes. Results The emergence of the intervention was guided by technical, legal and political motivations. The implementation was done in four phases. The first phase targeted the Level four (4) and five (5) facilities who had greater experience with revenue management and already had some level of autonomy, while the second phase built on the lessons learnt and targeted level three (3) and two (2) facilities. The last phase focused on institutionalization and continuous improvement of the standard budgeting process. Early findings showed improvements in budgeting practices in higher level facilities but minimal in level two (2) facilities with some contextual factors such as availability of management staff playing a role. Conclusion The experience of Nakuru county in building budgeting capacity for facility financial autonomy demonstrates that sustained progress requires a multi-year, adaptive approach that combines training with standardized tools, institutional support, and routine performance monitoring. This journey offers valuable lessons for effective decentralization: tailor support by facility level, embed monitoring and accountability mechanisms, and foster strong leadership and partnerships to sustain gains and enable responsive, autonomous health service delivery. Competing Interest Statement The authors have declared no competing interest. Funding Statement This work was funded by the Gates Foundation (GF) Investment name, HECTA Kenya Performance Management and Investment ID INV-074295. The funders had no role in the conceptualization, design and writing of this manuscript. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Scientific and Ethics Review Committee of Africa Medical Research Foundation (AMREF Kenya) gave ethical approval for this work under approval number ESRC p1830/2025. The study has also received approval from the Kenya National Commission for Science, Technology and Innovation (NACOSTI) under license number: NACOSTI/P/25/416429. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability Statement All data that are relevant for peer review and learning are available in the manuscript. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license . Back to top Previous Next Posted March 19, 2026. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. 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