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

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.