Joint Mission on Harmonizing Support to RH in Kenya 2011 1 1 Joint Mission on Harmonizing Support to...

Joint Mission on Harmonizing Support to RH in Kenya 2011 1Joint Mission on Harmonizing Support to RH in Kenya 2011 1

Joint Mission on Harmonizing Support

to Reproductive Health in Kenya

Preliminary Results and RecommendationsNairobi, 03-03-2011

Overview of mission

Commissioning partners:DANIDA, DFID, GDC, USAIDTogether with MOPHS, MOMS, BMGFDuration: from 13th February to 4th March, 2011Field visits to: Nyanza, Western, Eastern, Coast ProvincesNairobi: Korogocho, Dondera, Stahere slums

Joint Mission on Harmonizing Support to RH in Kenya 2011 2

Overview of presentation

1. Distribution of Commissioning DPs2. Overview of Financing3. Appraisal of Thematic Areas and Framework4. Ways of Working (“Modalities”)5. Health System re. RH (Supply Side)6. Demand Side Interventions7. Complementary Health Service Provision8. Adolescent SRH and SRH-R9. Next Steps


1. Distribution of Commissioning DPs


Incidences of Overall Poverty (%) 2005/2006 versus DP Presence

To be inserted


KENYA POVERTY LINE=46%

ABOVE POVERTY LINE

BELOW POVERTY LINE

DFID

BMGF

GIZ

KFW

DANIDA

USAID

Sources: WMS series 1992,1994 and 1997;KIBHS 2005/06

49%

52.2%

21.3%

51%

69.7%

50.9%

73.9%

47.6%

Skilled Birth Attendance (%) - 2008/09 versus DP Presence

To be inserted


Greater than national average

Less than national average

DFID

BMGF

GTZ

KFW

DANIDA

USAID

Source;KDHS

34%

26%

89%

74%,

46%

43%

32%

46%

Kenya: 44%

2. Overview of Financing


Examples of GoK and DPHK reporting of spend

on Reproductive Health


Ministries’ Reporting on Reproductive Health

(Printed Estimates for FY 2010- 2013)


Program Expenditure category Projected Estimates (Kshs Millions)

FP/MCH 2009/10 2010/11 2011/2012 2012/2013

Personnel Emoluments 42.5 62.2 108.6 112.6

Purchase of commodities 37.4 26.5 30.5 35.1

OBA program (admin) 63.0 62.0 71.3 82.0

Purchase of capital goods 20.0 20.0 23.0 26.5

Others 1,215.6 1,042.1 1,198.4 1,378.2

sub-total - FP/MCH 1,378.4 1,212.9 1,431.8 1,634.4

Child Health Services - - - -

O&M 7.4 6.3 7.2 8.3

Other recurrent 0.5 0.1 0.1 0.1

sub-total - CHS 7.9 6.3 7.3 8.4

GRAND TOTAL - RH 1,386 1,219 1,439 1,643

TOTAL HEALTH BUDGET 40,826 41,500 53,772 54,431

RH as % of total health budget 3% 3% 3% 3%

Approved Estimates (Kshs Millions)

DPHK Reporting on Reproductive Health


AOP6 PLANNED INPUTS

(2010-11)

USD($)RH

commodities condomsRH

O&MMCH

commoditiesMCH

O&Mnutrition

O&M TOTAL

AFDB $0

CLINTON $0

DANIDA $0

DFID $6,043,976 $397,630 $6,441,606

EU $1,400,727 $1,400,727

FRANCE $0

GAVI $35,053,500 $532,000

GTZ $5,599,840 $4,619,868 $10,219,708

KFW $0

ITALY $0

JICA $183,506 $183,506

UNAIDS $0

UNFPA $1,000,000 $1,429,500 $2,429,500

UNICEF $1,300,000 $6,300,000 $5,739,738 $13,339,738

USG $12,670,000 $3,675,000 $16,345,000

WFP $11,241,728 $11,241,728

WHO $497,000 $282,750 $779,750

WORLD BANK $6,400,000 $6,400,000

TOTAL $12,643,816 $6,400,000 $21,097,504 $35,053,500 $11,907,727 $17,264,216 $104,366,763

Finances for Health & RH• Two costed strategies – Average is $215 million

National Road Map for MNH and Child Survival Strategy (2008): $50 and $380 million per year respectively.

• WHO cost estimate per head for scaling up maternal health of $1.40, implying an additional cost for Kenya of $60 million.


Finances for Health & RH

Kenya Total Resources for Health Estimated Resources

for RHin US$ mio

GoK 550 25DPs 600 104Households 275 60TOTAL 1,425 190


Finances for Health & RH

• Could have sufficient resources for RH.• The single largest cost component in both

strategies is CHWs: $20m in the Road Map, $90 million in the Child Survival Strategy.

• Out-of pocket expenditure on (reproductive) health: private sector and demand side approaches have potential.

• BUT – Additional RH components (e.g. ASRH, gender violence) and will raise total cost.


Health Financing- Allocation of Resources (1)

DP Resources 2009/10 WHO for RHRecommendations

Procurement 42% Drugs & supplies 48% Service Delivery 55% Staff salaries 22%Infrastructure 3%

Support Systems 2% System dev. 25% (incl infrastructure, training)


Health Financing- Allocation of Resources (2)

• DPs spending about the right amount for commodities

• Too little being spent on systems development (and infrastructure)

• DP vertical spending - overwhelmingly on HIV/AIDS.• PETS – over 50% leakage Recommendation: • Resources looking adequate – the task for RH is to

allocate resources more effectively.


Health Financing

2009 Health Financing Strategy has stalled – KNHIF proving difficult to tackle and progress v slow.

Recommendation:• “Plan B” carry on with demonstrating

alternatives that work on the ground with well designed pilots: social insurance (HAKI)


Health Financing

• Vouchers / OBA scheme puts RH purchasing power into women’ hands and is effective and popular with women and service providers.

• High admin costs should be reduced if scaling up; • International evidence that voucher schemes costly

and unsustainable. Don’t seek to transfer costs to GoK, instead use OBA to direct DP resources to give more women decent, subsidised, urgently needed RH services.


3. Appraisal of Thematic Areas and Framework



Technical Appraisal

In mapping donor support the policies and strategies to identify gaps and areas for support we looked at DPs current support to RH against :

• Vision 2030• NHSP 2• RH Strategy• MNH Road map• AOP funding

Technical Appraisal

Policy environment: • Numerous policies and strategies

(65 strategies in RH Strategy);• Good information on unit costs;• Insufficient analysis of cost-effectiveness;But no document prioritising support to RH

- leading to a fragmented approaches and inefficient use of available resources.



Technical Appraisal

We found • clustering of support around

SMNH and FP• seemingly much less support for

adolescent sexual and reproductive health (ASRH), gender and sexual and reproductive rights (SRH-R).

Recommendation:• More should go to ASRH and SRH-R

Policy / Community Strategy

• Concerns about cost effectiveness, opportunity cost to train more CHWs

• Concerns about SRH impactRecommendations:• Immediate: Get a common understanding about the

revised Community Strategy, its evidence base and cost implications (also in view of RH B.P.)

• Medium-term: Support if and where feasible, provide training and tools


4. Ways of Working (“Modalities”)



Immediate Recommendations

DPs provide TA to DRH to develop a strategic RH costed business plan to reduce MNM – - covering public and non-state actors – - showing what is needed, - where and how it should be delivered - prioritised and highlighting gaps.

Agree on one TA plan reflecting all TA required. Agree on one RH commodity plan.

Why an RH Business Plan?

Technical Efficiency;It will help ensure more efficient use of

available resources; Can be used to mobilise resources with DPs

and MOH and MOF;Used by DRH to lead, coordinate and review

support to RH;DPs should report funding against main themes

in the BP – transparent tracking of resources.Joint Mission on Harmonizing Support to

RH in Kenya 2011 25

Ways of Working DPs with MOH (1)

• More adherence to Paris Declaration and Code of Conduct.

• Support the SWAp process, at minimum by joint planning around existing funding baskets: HR, EMMS, HSSF

• Joint annual review of RH by all partners – feeding into annual Health Summit and SWAp.



• Use a core set of indicators to measure and monitor RH.

• Support the TA RH plan with a pooled fund (managed independently) – at minimum joint TA RH plan

• Pool support for RH commodities to EMMS – minimum one plan reflecting all support to RH commodities.



• Report funding against agreed areas of RH.• Harmonize approach to per diems in RH.• Ensure that IPs work with the districts and

AOP process – include in MOU with IP.• Provide TA (Health Systems Adviser) to DRH –

maternal mortality is a systems failure , will ensure strategic planning and linkages to the SWAp process.




• DRH – needs to be more strategic and tell DPs what is required and where – less advocacy more action.

• RH – ICC should play a more strategic role using the RH Business Plan to assess performance against the plan, funding and agreed priorities.

• RH - ICC commodities should be stopped and quantification covered by procurement ICC.


• Districts – ensure effective stakeholder coordination

• Define principles of engagement at district level – should be developed into a binding code of conduct

• Provide TA to support this process in districts


Operational research Knowledge management

• OR – fragmented as often driven from outside country (global funding).

• Lack of proactive knowledge management Recommendations:• Use RH ICC to decide on priority OR – relate to

RH B.P.• RH - support to establish focal point (TA) for

knowledge management


5. Health System re. RH services(Supply Side)


Leadership and Governance (1)

Insufficient leadership and governance for RHRecommendations:• Upgrade management skills• Match person-to-post to ensure leadership• Streamline data management to support planning at

all levels • Include total market approach (e.g. PPP)• Comprehensive policies and guidelines to guide

Counties Joint Mission on Harmonizing Support to

RH in Kenya 2011 33

Leadership and Governance (2)

• Health Sector Policy – A broad participation in the revision process and

ensure RH needs are sufficiently addressed

• Devolution process to Counties – Immediate: Provide TA to MOPHS in the planning of

devolution– Support professional advocacy campaign on RH– Medium-term: Support devolution process in RH– Support MOPHS to provide TA to Counties in their

planning and implementation stage Joint Mission on Harmonizing Support to

RH in Kenya 2011 34

Human Resources for Health (HRH) (1)

HRH - Maldistribution urban / ruralRecommendations:• MOH – Agree on redistribution plan and

incentives, money and non monetary• Inform further HRH planning about

implications of devolution to Counties • DPs - Support incentives through HRH pooled

fund


Human Resources for Health (HRH) (2)

Skilled Birth attendance (SBA) not available at lower levels. i.e. dispensaries, Health Centres

Recommendations:• Immediate: Increase training on safe delivery at

levels 1 to 3 using centres of good practice and existing training modules (funded through TA pot)

• Medium Term: DPs to support recruitment of additional nurses through HR pot (after redistribution).


High Impact Interventions

Low coverage of High Impact InterventionsRecommendations:• Integrate into RH B.P. - Focus on agreed RH

outcomes• Immediate: DP/IPs to prioritize support to the

Acceleration Plan• Address issues of access, equity, quality and

sustainability Joint Mission on Harmonizing Support to

RH in Kenya 2011 37

Low utilization of RH services at HF – level 1-3 (1)

Stock-outs, erratic delivery of FP / RH commodities to HF, no consumables, poor environment - cause of informal user fees

Recommendations Supply Side Interventions:• Review division of labour between RH

coordinator and pharmacist• Integrate all RH/FP commodities into the

supply chain management system



Recommendations Supply Side Interventions:• Support RH commodities through EMMS

earmarked pot.• Develop mechanisms to cover costs for

consumables, auxiliary staff (e.g. HSSF) • Scale up infrastructure improvements to

dispensaries for safe deliveries


Low utilization of RH services

High unmet need for FP methodsRecommendations:• Immediate: Assure the availability of complete

range of contraceptives in HF • Train staff in IUCD and implant insertion• Scale-up promotion of LAPM and services• Include FP into combined RH OBA voucher• Integration of FP into VCT and PMTCT


6. Demand Side Interventions



Demand side interventions for RH to reduce barriers to RH services:

• Address counterproductive practices and fears (BCC and practical solutions at HF)

• Engage women’s groups and male involvement• Create and maintain Community Fund to cover

transport or user fees• Community partnering with local transport industry



Recommendations: • Organize knowledge sharing of good practices

from the different regions • Medium-term: Support further piloting and

implementation of pre-payment (e.g. voucher) and health insurance schemes



High unmet need for FP methodsRecommendations:• Disseminate messages addressing particular

reservations about FP• Address particular needs of adolescents• Continue to support special promotion of

under-utilized FP methods (e.g. LAPM)• Support targeted communication campaigns


7. Complementary Health Service Provision

(“Total Market approach”, PPP”)


Total market approach and PPP (1)

Missed opportunities to use complementary services for different population groups, involving public and non-state actors (NGO, FBO and private sectors) in achieving Health MDGs

Recommendations:• Immediate: DPs continue to advocate for PPP • Medium-term: Include non-state actors in RH

Business PlanJoint Mission on Harmonizing Support to

RH in Kenya 2011 46

Total market approach and PPP (2)

• Continue to support social franchising and OBA scheme with non-state service providers

• Pilot sub-contracting integrated RH services to FBOs in underserved areas (performance based)

• Continue to establish PPPs with companies


8. Adolescent SRH and

SRH-R


Adolescent SRHR (1)

Teenage pregnancies – important part of MMR Recommendations:• Give high priority to comprehensive RH in in-

school and out-of-school programmes • Assure that RH and SRH-R aspects of existing

curricula are covered in actual teaching• Partner with youth associations to address

teenage RH and income needs


Adolescent SRHR (2)

Bias of health service providers against adolescents and unmarried youth

Recommendations:• Train health staff to be responsive to youth needs

without prejudice (“youth lens”)• Increase set-up of Youth-friendly RH Services in HFs

and in (e.g.) youth centres• Support YFS in non-health settings (e.g. schools –

MOE, youth empowerment centres - MOYAS


SRH-R - Gender-Based Violence

High level of gender-based domestic and sexual violence

Recommendations:• Immediate: Coordinated response among all

actors • Utilize Technical Working Group on GBV


9. Next Steps


Priorities on Demand and supply side interventions• Assure availability and quality of obstetric care

at Level 1 to 3 and referrals through complementary providers

• Assure availability of diverse options for family planning

• Assure demand side measures for decision-making, financial and geographic accessibility

• Assure comprehensive RH information and services for adolescents in and out-of-school


Next Steps towards DP harmonization• Develop RH Strategic Costed Business Plan• Complete Gaps Analysis of DP Contributions• Harmonize Interventions through Stakeholder

Code of Conduct at National and District Level• Create TA Pooling Mechanism• Provide TA to devolution process re. RH• Rationalize RH Supply Chain Management• Create High Visibility of RH through Advocacy

and Targetted CommunicationJoint Mission on Harmonizing Support to

RH in Kenya 2011 54

Thank you for your attention and support!

Luise Lehmann, Kawaye Kamanga, Dhimn Nzoya,

Marilyn McDonagh, Rachel Phillipson


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