Public health care in Sub-Saharan Africa has gone through a long period of increasing shortage of human as well as financial resources for health. Inadequate procurement systems, public service delivery that is not accountable and inefficient supervision are important problems of public systems in poor countries [2, 3]. According to the results in this study, Kenya is no exception.
Increased resources were provided for the financial year 2005/06, which gave policy makers an opportunity to allocate increased funds towards prioritised areas without necessarily cutting from other areas. The allocation of funds from the central level in the Kenyan health care sector, however, goes in part against set policies and the reallocations of funds between line items at district level creates further deviations between set policies and implementation. Also in a previous study of health sector reforms in Kenya it was concluded that there is a large gap between policy formulation and implementation . In the current study it was found that that there are considerable gaps between the printed and approved health budgets and actual health expenditures in general and for the development component in specific. A large part of the gap is explained by delays in the allocation of funds and a slow procurement system, resulting in an inability to spend allocated funds. Funds that are not spent by the end of the financial year cannot be carried forward and spent in another period. Moreover, a reallocation of funds towards curative services has taken place. This reallocation has meant that allocated funds are spent against policy directions and prioritised areas since it is clearly articulated that resources should be allocated towards primary and promotive services. Thus, an increased ability to spend allocated funds might lead to a higher degree of policy implementation. Efforts towards a quicker release of funds through disbursements on pre-financing arrangements, which was introduced in 2005, might improve the absorption capacity at the district level.
Scarce resources for health make it in practice difficult for policy makers to prioritise one area without cutting from other areas. In a resource constrained environment, reallocating funds inevitably creates 'winners and losers', and thereby tensions [26, 27]. But even allocating extra funds can create tensions as those who do not receive as large increments as others perceive themselves as losers. Implementing unpopular decisions requires both capabilities and incentives among those with the task of implementation. Failure of implementing reallocations can often be expressed in terms of failure of will as decision makers lack the will of implementing unpopular decisions .
Franco et al, 2002, define incentives as the "will-do" component and capabilities as the "can-do" component and of individual motivation . Capabilities relate to the extent to which resources including skills are mobilised to enable the achievement of set goals or priorities. Incentives relate to the extent to which human resources adapt to those goals and are affected primarily through feedback related to job performance and work culture. Strengthened strategic and operational capacities are necessary for the capability to act. But having the capability to act is not similar to having the incentives to act. Both capabilities and incentives are necessary conditions for change [29–31].
Current budgeting practises constitute a problem of gaps and delays in allocation and disbursement of funds at the district level. Thereby the control over financial resources at district level becomes weak. Further, weak managing and planning capabilities and a poor procurement system carry an inability to actually spend disbursed funds, i.e. the "can-do" component seems to be weak. The problems might be related to an unclear definition of roles and responsibilities at as well as poor communication between different levels of the system. The current top-down approach to the planning and budgeting system means that funds allocated to districts and hospitals by the central level with no clear linkages between the districts and the MoH. Thereby the districts are given directions that do not necessarily coincide with their preferences or perceived priorities, i.e. the incentives of implementing budgets set by the central level or the "will-do" component might be weak. Also in a previous study of Kenya it was found that, in order to achieve desired outcomes of health policy processes, systematic management, monitoring and evaluation of processes are crucial .
The interaction between spending and cutting roles constitutes a budgetary system . In poor countries, the definition of roles might be even more important than in rich countries.
According to Wildavsky (1986), in poor and uncertain countries, repetitive budgeting is found. Finance ministries in these countries generally approve budgetary estimates ex ante but when it is time to disburse the funds payments are delayed. Poverty carries a delay in the disbursement of money and uncertainty carries a need to reprogram funds repeatedly to adjust to the changing conditions in the system . In such countries, it is often easier to work with improved roles and responsibilities rather than overall budgetary poverty and uncertainty. As Gauri (2001) suggest, in developing countries with poor quality and inequitable distribution of health care services, a key function of the funding body is to define responsibilities of different types of providers and levels of care, and organise the available resources accordingly .