Abstract
BACKGROUND: Effective public financial management (PFM) is a foundational enabler of sustainable progress toward Universal Health Coverage (UHC). Achieving UHC requires not only increased funding for the health sector but also the efficient, equitable, and accountable use of resources. In 2019, Kenya piloted a UHC initiative across four counties to generate evidence to inform national scale-up. This study examines the PFM processes underpinning the pilot implementation, with a focus on how financial planning, budget execution, and accountability mechanisms influenced the delivery of UHC interventions at the county level. METHODS: This study employed a qualitative research design to explore PFM processes during the implementation of Kenya's UHC pilot in four counties. Data were collected through 51 in-depth interviews and five focus group discussions with key stakeholders, including healthcare workers, patient representatives, and senior members of the County Health Management Teams (CHMTs). An inductive thematic analysis approach was employed to identify patterns and themes that emerged from the data. The analysis was facilitated using Dedoose software (Version 9.0.17), which enabled systematic coding and organization of the qualitative data. RESULTS: The UHC pilot program in Kenya featured a hybrid planning model, combining top-down directives from the national government with bottom-up inputs from county stakeholders. Despite this collaborative approach, county budgeting processes remained governed by the stipulations of the PFM Act. While counties welcomed additional UHC funds, the removal of user fees led to reduced facility-level revenue, increased service demand, and strain on human and material resources. Delays in fund disbursement, rigid budget structures, and limited financial autonomy further constrained implementation. These experiences underscore the need for a more coherent integration of PFM and health financing policies at the subnational level to ensure sustainable and equitable health service delivery. CONCLUSION: The UHC pilot offers critical lessons for future health financing reforms. Addressing PFM bottlenecks-particularly those related to timely disbursement, budget flexibility, and local revenue generation-is essential to ensure the sustainability of UHC in Kenya and similar contexts. The study's limitations necessitate further research before scaling up nationwide.