Republic of Kenya

NHSSP IIMidterm Review

Report

Reversing the TrendsThe Second National Health

Sector Strategic Plan

Ministry of HealthNovember 2007

Republic of Kenya

i

NHSSP II

Midterm ReviewReport

Reversing the TrendsThe Second National Health

Sector Strategic PlanRepublic of Kenya

Ministry of HealthAfya House, Nairobi, Kenya

PO Box 30016 - General Post OfficeNairobi 00100, Kenya

Email: secretary@hsrsmoh.go.keWebsite: www.hsrs.health.go.ke

November 2007

ii

ANY PART OF THIS DOCUMENT may be freely reviewed, quoted, reproduced or translated in full or inpart, provided the source is acknowledged. It may not be sold or used in conjunction with commercialpurposes or for profit.

Reversing the Trends: The Second National Health Sector Strategic Plan of Kenya – NHSSP IIMidterm Review Report

Published by: Ministry of HealthSector Planning and Monitoring DepartmentAfya HousePO Box 3469 - City SquareNairobi 00200, KenyaEmail: hsrs@health.go.kehttp://www.hsrs.health.go.ke

iii

Contents

List of Tables and Figures ivList of Abbreviations vForeword viiAcknowledgements ixExecutive Summary xi

1. Introduction 1Policy Shifts in NHSSP II 1About this Report 1

Objective of the Midterm Review 2Methodology and Process of Development 3Flow of the Report 3

2. Progress with Objective 1: IncreasingEquitable Access 4

Recap of Expectations 4Progress with Implementation in Line with

KEPH 5Cohort 1: Pregnancy, Delivery and the Newborn5Cohorts 2 and 3: Early and Late Childhood 7Cohort 4: Adolescence 9Cohort 5: Adult/All Life Cohorts 9Cohort 6: Elderly 10

Progress with Implementation of Strategiesto Improve Access 10Improving Geographical Access 10Improving Financial Access 13Addressing Social-Cultural Barriers 14

Summary of the Major Recommendations 14

3. Progress with Objective 2: ImprovingService Quality and Responsiveness 15

Improving Health Worker Performance 15Improving Responsiveness to Client Needs 16Summary of Major Recommendations for

Improving Service Quality andResponsiveness 17

4. Progress with Objective 3: ImprovingEfficiency and Effectiveness 18

Improving Value for Money 18Improving Financial Management with Focus

on Flow of Funds 18Improving Planning, Management

and Administration 20

Community Interface 20Planning System 21Performance Monitoring 22Human Resources 25Procurement and Commodity SupplyManagement 26Investment and Maintenance 29Communication and ICT 29

Recommendations for Improving Efficiencyand Effectiveness 30

5. Progress with Objective 4: FosteringPartnership 32

Joint Planning and Priority Setting 32Joint Monitoring 34Pooling of Funds 34Stewardship, Leadership 35Recommendations to Improve Collaboration

and Partnership 36

6. Progress with Objective 5: ImprovingFinancing of the Health Sector 37

Assumptions 37Increased Government Allocations to Health 38Rise in User-Fee Revenues (Public HealthFacilities) 38Rise in Bilateral and Multilateral FinancialAssistance 38

Analysis of Performance 38Per capita health spending 39Actual Expenditures Compared withApproved Budgets 39

Issues in Public Spending on Health 39Alternative and Innovative Financing

Mechanisms 40User Fees 41National Social Health Insurance Fund 41Other Financing Mechanisms 41Improving the Allocative Efficiency 42

Recommendations to Improve the Financingof the Sector 43

References 44

iv

List of Tables and Figures

1.1: Progress in the realization of policy shiftsin the health sector 2

2.1: Status of indicators against review targets 52.2: Achievements of targets for cohort 1 62.3: Achievements of targets in cohorts 2

and 3 72.4: Achievements of targets in cohort 5 92.5: Infrastructure improvements 122.6: Staff recruitment 2006/07 133.1: Reduction in waiting time in hospital

RRI 164.1: District resource allocation criteria 186.1: Scenario 1 projected funding on health

(million Ksh) 386.2: Scenario 2: projected funding on health 386.3: Trend in public expenditures on health 386.4: Estimated available resources vs.

projected flows 396.5: Per capita health spending in Kenya

compared with selected benchmarks(US$) 39

6.8: 2006/07 MOH budget (gross) disaggre-gated by levels (Ksh million) 42

6.6: Trends in expenditures as percentageof total MOH budget 42

6.7: Distribution of MOH recurrent budgetallocation by economic categories(percentage) 42

2.1: ANC client coverage (4 visits), percentage 62.2: Percentage of WRA receiving family

planning commodities 62.3: Percentage of deliveries conducted by

skilled attendant in health facilities 62.4: Children <1 year immunized against

measles (%) 72.5: Children <1 year fully immunized (%) 72.6: Use of ITNs by wealth quintile following

mass distribution, 2004–2007 in Kenya 82.7: Lorenz concentration curve for children

using ITNs, 2004–2007 82.8: Progress against Abuja targets in Kenya

2001–2006 82.9: Adult HIV prevalence, 2001–2006 92.10: Estimated deaths averted because of ART

scale up 102.11: National health facility completion (%),

2001–2006 126.2: Approved and actual expenditures

compared 39

Tables Figures

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AIDS Acquired immune deficiency syndromeAOP Annual operational planBEOC Basic essential obstetric careCDF Constituency Development FundCEOC Comprehensive essential obstetric careCE Chief EconomistCFO Chief Finance OfficerCHEW Community Health Extension WorkerCHW Community Health WorkerCOC Code of ConductCU Community UnitDANIDA Danish Development AgencyDHMT District Health management TeamDHRM Department of Human Resource

ManagementDHS Demographic and Health SurveyDMS Director of Medical ServicesDFID Department for International

DevelopmentDP Development partnersDRH Division of Reproductive HealthEMS Essential Medical SuppliesEDL Essential drug listGDC German Development CooperationGDP Gross domestic productGOK Government of KenyaH/C&RS Head, Curative and Rehabilitative

ServicesHENNET Health Non-Governmental

Organization NetworkHIV Human immuno-deficiency virusHMIS Health management information

systemH/PPHS Head, Preventive and Promotive Health

ServicesHR Human resourceHRH Human resource for healthHRM Human resource managementH/SPMD Head, Sector Planning and Monitoring

Department

List of Abbreviations

HSCC Health Sector Coordinating CommitteeHSSF Health Sector Services FundICC Interagency Coordinating CommitteeICT Information and communication

technologyIDSR Integrated Disease Surveillance and

ResponseIFMIS Integrated financial management

information systemIP Implementing partnerIRT Independent review teamISO International Standards OrganizationIMR Infant mortality rateIPT Intermittent presumptive treatmentIRT Independent review teamITN Insecticide treated netJFA Joint Financing AgreementJICA Japanese International Cooperation

AgencyJPWF Joint Programme of Work and FundingJRM Joint Review MissionKsh Kenya shillingKDHS Kenya Demographic and Health SurveyKEMSA Kenya Medical Supplies AgencyKEPH Kenya Essential Package for HealthKHPF Kenya Health Policy FrameworkKHSWAp Kenya Health Sector-Wide ApproachKNBS Kenya National Bureau of StatisticsKSPA Kenya Service Provision AssessmentMDGs Millennium Development GoalsMEDS Mission for Essential Drugs SupplyMMU Ministerial Management UnitMOH Ministry of HealthM&E Monitoring and evaluationMTEF Medium-term expenditure frameworkMTCs Medicines and Therapeutic CommitteesMTR Midterm reviewNCDs Non-communicable diseasesNGO Non-governmental organizationNHA National Health Account

vi

NHISF National Health Insurance FundNHSSP II Second National Health Sector

Strategic PlanNSHIF National Social Health Insurance FundPAC Principal Accounting ControllerPER Public expenditure reviewPETS Public Expenditure Tracking SurveyPHMT Provincial Health Management TeamPFM Public financial managementPME Performance-based monitoring and

evaluationPMIS Procurement management information

systemRBM Results based management

RH Reproductive healthSWAp Sector-wide approachSC Service CharterSOP Standard operation procedureTB TuberculosisTCR Treatment completion rateTNA Training needs assessmentTWG Technical Working GroupUNFPA United Nations Population FundUS$ United States dollarUSG United States governmentWHO World Health OrganizationWB World Bank

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Foreword

viii

ix

Acknowledgements

x

xi

Executive Summary

Kenya’s second National Health SectorStrategic Plan (NHSSP II) defined fivemain objectives and ten strategic shiftsthat would drive its implementation

over the plan period, 2005–2010. The intention wasto reverse the downward slide in Kenya’s healthindicators and align health sector achievementswith the Economic Recovery Strategy (ERS) and theMillennium Development Goals (MDGs).

As the life of the plan approached its midterm,it was necessary to review progress made towardsthe goals. The extent to which they are being realizedis outlined in the various chapters of this report ofthe Midterm Review (MTR). The assessment wascarried out by an independent review team and thereport was developed under the leadership of theJoint Review Mission (JRM) steering committee,which provided valuable comments on the draft thatwere then incorporated into this version.

Among cross-cutting achievements were thearticulation of a sector-wide approach (SWAp) toheath services delivery and the institution of local,district and provincial stakeholder forums. But whilethe MTR found significant progress in some areas,achievements in others were less impressive.Accomplishments during the first half of NHSSPII are briefly summarized below according to thefive main objectives. This is followed by a selectionof the major recommendations for the way forward.

Summary of Achievements

AccessMany achievements have been made in expandingthe coverage of facilities, institutionalizing the needsof clients and improving pro-poor financing.Significant among these were the implementationof the first phase of the Kenya Essential Packagefor Health (KEPH) and the development and rollout of the Community Strategy.

QualityGovernment-wide institution of results-basedmanagement has underpinned the performanceappraisal. A recent pay rise for health workers hasalso provided a conducive environment for reform.Many clients are more satisfied with the services.

PartnershipsCommendable planning frameworks have beendeveloped, and the health sector is rapidlydecentralizing its planning process. Commitmenthas been shown on all sides to substantiallystrengthen partnership arrangements.

Efficiency and EffectivenessProgress is being made to enable funds to flowdirectly to lower level service delivery. The HealthSector Services Fund (HSSF) pilot shows that thisis likely to accelerate service delivery outputs. Planshave been developed to strengthen certain healthsystems.

FinancingResources have increased, and allocative efficiencyhas improved with more funds channelled to costeffective basic health services. Resolving bottlenecksin spending GOK funds is being addressed as apriority.

NHSSP II Objectives1. Increase equitable access to health

services2. Improve the quality and responsiveness of

services3. Foster partnerships in improving health and

delivery services4. Improve efficiency and effectiveness5. Improve financing of the health sector

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Summary of Recommendations

These are also organized according the five objectivesof NHSSP II. In some cases the list of suggestionsis long and they are only outlined here; details arecontained in the body of the report.

Accessw Strengthen the delivery of the KEPH by accelera-

ting implementation of the following focal areas:Safe motherhood, Community Strategy,Malaria, TB and non-communicable diseases,and developing implementation frameworks forproviding services to cohorts 4 and 6.

w Address remaining barriers to equitable accessthrough continued dialogue with theConstituency Development Fund (CDF) Com-mittee, review of innovative service deliverymechanisms for improvement and scaling upservices to remote hard-to-reach areas;recruitment and deployment of the 9,000approved posts, and further reallocations ofpublic funding towards pro-poor programmes.

w Make the Community Strategy more inclusiveby bringing on board all interested parties andresolving issue on terms of conditions of CHWs.

Service Qualityw Strengthen systems and capacity for effective

integrated support supervision and qualityassurance programme at all levels.

w Accelerate the dissemination of updated clinicalstandards, protocols and guidelines for theKEPH including the ministerial service charter.

w Logistics chain management for essential andpublic health goods needs to be strengthened inGOK and PNFP facilities.

w Develop strategies for improving provider-clientrelationships and accountability includingdevelopment of health specific charters.

Efficiency and Effectivenessw Improve value for money by undertaking further

reallocations of public funding towards pro-poorprogrammes especially rural health services inlight of current poverty levels that justify morewavers of facility fees to alleviate financialconstraints to health services access by the poor.

w Improve public financial management byimplementing the Health Sector Service Fund(HSSF), enhancing collaboration withdevelopment partners, and fast trackingcapacity building in financial management.

w Strengthen district health planning.w Ensure that gender and rights sensitivity are

included in training materials and planningformats and consider the establishment of a focalarea at the national level to coordinate thiswork.

w Improve monitoring through a variety of stepsto enhance the national health managementinformation system and undertake essentialhealth research.

w Improve public procurement by, among others,accelerating the implementation of theprocurement improvement plan.

w Strengthen commodity supply management, bydelineating roles and responsibilities of MOHand KEMSA, and define the role of KEMSA vis-à-vis non public actors and introducing qualityassurance mechanisms.

w Enhance investment and maintenance ininfrastructure , communication and transport.

Efficiency and Effectivenessw Develop a roadmap for advancing the Kenya

Health SWAp and governance structures forannual planning to be agreed and the HealthSector Coordinating Committee (HSCC)mandated to monitor its progress.

w Articulate clear benchmarks to ensureadherence by all parties to the Code of Conduct(COC) and ensure the SWAp is advanced.

Partnershipsw Formulate a public-private partnership policy

framework, but give priority to addressingissues relating to private not-for-profit providersinvolved in direct service provision.

w Set national targets for indicators of progresson aid effectiveness per the Paris Declaration(ownership and leadership, alignment togovernment strategies and priorities, andmutual accountability for results andharmonization) within the NHSSP II M&Eframework.

Financingw Increase the level of health financing through

improved lobbying for adherence of GOK budgetprojections and donor commitments.

w Improve budget management and exploremechanisms for efficient and equitable resourceallocation and utilization.

w Finalize and implement a long-term healthfinancing strategy.

w Review NHIF Act to adjust the benefit ratio;limit administrative spending; mandateexpansion of the benefit package to outpatientservices; change the contribution to a percentage/ratio of salary instead of fixed rates; andregulate non-benefit payments/contributions tothe health sector.

w Incorporate NHIF spending/income from NHIFreimbursement into financial planning of sectorand health institutions.

1

D eveloped and approved for imple-mentation in 2005, Kenya’s secondNational Health Strategic Plan(NSSSP II, 2005–2010)1 aimed to

reverse the downward slide in the country’s healthindicators. The plan outlines five major strategicpolicy objectives: 1) increase equitable access; 2)improve service quality and responsiveness; 3)improve efficiency and effectiveness; 4) fosterpartnership; and 5) improve financing.

These strategic objectives are designed to beachieved through a shift of focus and commitmentin the management of the health sector.

Policy Shifts in NHSSP II

NHSSP II was developed on the basis of twomajor principles: reversing the declininghealth trends and achieving the high

targets set in the Economic Recovery Strategy (ERS)and the Millennium Development Goals (MDGs). Ifthe management of the sector continued businessas usual – as was the case in NHSSP I – it wasrecognized that the targets would not be achieved.Therefore NHSSP II focused on changing themindset of health managers in a holistic approachto sector management, appreciating the involvementand responsibility of other actors, orientation toresults rather than to processes and procedures, andutilization of flexible and learning approaches.

NHSSP II defined ten strategic shifts that woulddrive its implementation. As the life of the planapproached its midterm, it was necessary to reviewprogress made in each of these areas. The extent towhich they are being practised is reflected in the

1. Introduction

various chapters of this report. Progress issummarized in Table 1.1.

About this Report

The Plan has been carried out in the last twoyears through the development andimplementation of Annual Operational Plans

1 and 2. One of the major strategies designed inNHSSP II has been the move towards sector wideapproach, which requires a regular joint reviewsand evaluations on a regular basis. In the Kenyancontext, GOK is expected to organize a MidtermReview (MTR) and a final evaluation of the NHSSPII. These exercises were planned to take place beforethe end of the third year and during the last quarterof implementation year of NHSSP II, respectively,as per the draft of Code of Conduct (COC) andNHSSP II (page 49). All partners have jointlydetermined the terms of reference and thecomposition of the independent review team (IRT).

In view of the late schedule for the finalevaluation of NHSSP II, this midterm evaluationcould also serve as basis for initiating NHSSP IIIdevelopment process. It would be more efficient andcost effective to undertake the AOP 2 annual reviewand the NHSSP II MTR at the same time. Accordingto the terms of reference (TORs), the Joint ReviewMission (JRM) was to be carried out under theguidance of a Joint Government/developing partners/implementing partners Steering Committee JRM(Steering Committee). The Sector Planning andMonitoring Department would provide secretarial

1 Ministry of Health, Reversing the Trends – The SecondNational Health Sector Strategic Plan of Kenya: NHSSP II –2005–2010, September 2005.

NHSSP II aims to keep people well, rather thansimply treat disease, and to promote theinvolvement of communities in their own healthcare.

2

support. The Committee would be primarilyresponsible for:w Facilitating the Joint Review planning and

implementation process.w Refining the terms of reference (TORs) for the

JRM Independent consultancy team.w Undertaking the recruitment process of the

independent review team (IRT).w Facilitating the field visits.w Supporting the organization of the stakeholders

meeting.w Undertaking the policy dialogue.w Developing the JRM report and presenting to

the HSCC.w Organizing the Health Review Summit.

Objective of the Midterm Review

The objectives of the NHSSP II midterm review wereto obtain a comprehensive view asw To extent the NHSPS II policies and strategies

have been implemented?w To what extent has the NHSSP II implemen-

tation contributed towards the realization of thesector objectives and targets?

w What are the challenges and constrains inimplementation of the NHSSP II policies andstrategies and for realizing set objectives andtargets including the appropriateness andrelevance, of the policies and strategies inreversing the health trends?

Table 1.1: Progress in the realization of policy shifts in the health sectorNHSSP II plan

From To Current implementation status

Develop and implement a single “master plan” and adhere to its implementation.

Build a system of coordination and allow annual priority setting of the intended interventions.

The AOPs are institutionalized; There are still interventions being carried outside AOPs, which needs to be corrected

Ideas and solutions are fixed and can only be changed in the next period, implying one-off initiatives.

Embrace a continuous process of learning and adaptation to the changing environment, including MOH itself.

There is significant change in management of the sector in scanning the environment and learning from experiences. The annual JRM process contributes significantly to this learning approach.

Management is based on evidence only, no risk taking.

Management is based on piloting, and managing risks and uncertainties.

There have been e pilot interventions in new policy initiatives in the last two years: Community Strategy implementation, health facility funds, demand driven EMMS procurement system, demand side financing interventions

Narrow and structured participation in well defined activities, little collaboration and information sharing.

Multi-stakeholder approach, continuous review of plans and interventions; solicitation of participation of all on equal basis.

A Code of Conduct is signed on the partnership principles for the tripartite partners (government, implementing partners and development partners). Partners’ interventions are increasingly included in the annual planning process. There have been three health summits that brought all stakeholders together to plan and review the performance of the sector . The DHSFs are functional in most of the districts.

Services are provided on the basis of vertically organized programmes.

Services focus on the needs of various age-groups (cohorts).

KEPH under implementation. All the services out lined in KEPH have not been introduced yet.

Focus on projects and activities.

Focus on outputs and outcomes. Results based management and performance contracting & appraisal systems have been introduced. The Joint Programme of Work and Funding and the Joint support programme are laying the foundation for moving towards a programme approach.

Ministry alone takes responsibility.

All actors are equally responsible. Most actors are involved in planning monitoring and monitoring process but process of responsibility for sector actions is evolving.

In setting priorities, use only criteria of technical and effective interventions.

Priority setting also includes political criteria of access to and redistribution of power and resources within the country.

Not much progress is recorded

Continue the expansion of infrastructure at all levels.

Scale up community-based interventions and link them with the referral system.

Community Strategy implementation initiated and lessons learnt to enable linking the informal structure into the formal health system

Public sector fills the poverty gap through an essential health package; pro-poor targeting, but little change.

Public sector ensures redistribution of resources and social solidarity; structural change to bring everybody on board.

Not much progress in the sector, but there are processes initiated to support the FBOs/NGOs

3

The JRM steering committee decided toundertake the review internally with stakeholdersand to use an independent review team to verifyand provide objective recommendations. The MTRprocess involved the development of an MTR reportsby the MOH; the development of the IRT report tobe an input to the stakeholders meeting; and thereview of the implication of the findings of the tworeports in the stakeholders’ meeting that endorsedthe recommendations. This report therefore hasbrought the additional findings of the IRT team intothe original MOH report and presented thecomprehensive recommendations from the wholeprocess (MOH report, IRT comprehensive report,and the stakeholders meeting).

Methodology and Process ofDevelopment

The MOH MTR Report was developed under theleadership of the JRM steering committee. Thecommittee has reviewed the content of the reportand provided valuable comments for improvementwhich this version has incorporated. This documentis prepared using various sources of information.The annual performance reports of AOP 1 and 2,the district health information data have been themain sources for the various sections of the report.The results of surveys for service delivery areas andsystems by programmes and various reviewmissions have also been used. The IRT individualconsultants’ reports, along with the recommen-dations of the stakeholder meeting, have enrichedthe content of the report.

The gaps in the information from the varioussources have a negative effect on the quality of thereport. The quality and reliability of the district datacannot be ascertained as data quality assurance isnot fully functional. Only about 65% of the healthfacilities have reported for AOP 2. The systemssection of the report has been consolidated from thevarious reviews carried out rather than a systematicreports submitted. It still remains difficult to havea comprehensive expenditure report from all thesector players. Most of the donor and implementingpartner expenditures are not captured in this report.

Flow of the Report

The MTR report is structured in line with thestrategic objectives of the NHSSP II. The chaptersreview the extent to which the sector has achievedthe aims set in each objective. Chapter 2 looks intoincreasing equitable access to health services andthe strategies implemented, and Chapter 3 exploreshow far the quality of services are improved andrespond to the needs of clients. Chapter 4 assesesthe extent to which the system related reforms areimplemented to support the delivery of the definedhealth care services. Chapter 5 documents theprogress made regarding fostering partnership. Thelast chapter examines the resource flows andpresents how far the NHSSP targets in areas ofmobilizing additional resources and in improvingallocative efficiency are met.

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NHSSP II intends to increase equitableaccess to health care services byaddressing obstacles to accessing healthservices which are classified as

geographical, financial and social-cultural factors.It is assumed that breaking the barriers to accessingcare would result into increased utilization of healthcare services. NHSSP II emphasizes the focus onthe need to strengthen service delivery to ensure illhealth is limited amongst the people in Kenya. Thisis further elaborated in the policy objective toincrease in equitable access to health services.NHSSP II outlines how this is to be done, througha series of service delivery reforms, centred arounda defined set of service interventions, the KenyaEssential Package for Health (KEPH.)2

Recap of Expectations

At the end of NHSSP I, access to health careservices was found to be unequal across thecountry. The Kenya Service Provision

Assessment Survey 2004 found that 57% of facilitiescould provide a basic package of child, maternal,reproductive health and HIV/AIDS services, butonly 10% of clinics are able to provide 24-hourdelivery services.

The MOH Norms and Standards3 guidelinesuggests that average number of facilities per capitaper level appear to be adequate, with over-availability of level 2 and level 4 facilities. The normsfor facility availability are based on populations,however, and not on distance to nearest facilities,which is reported to be over 50km in some parts of

2. Progress with Objective 1: IncreasingEquitable Access

the country. Even at the health centre anddispensary level, the distance factor means thatadjacent populations are better served than remotevillages within the catchment population, adifference that is only partially offset by outreachservices. In the pastoral areas where populationdensities are low, average distance to a health facilityis inevitably greater than in cultivated areas, evenif catchment populations are identical. In theextreme case, static facilities are only infrequentlyaccessible by nomadic populations.

There were also huge geographical variationsin staff distribution for all cadres. For example, thedistribution of nurses in 2003 ranged from 2,874nurses per 100,000 in Central to 349 nurses per100,000 in North Eastern province (HR MappingStudy 2003), the disparity is likewise with doctorsand other cadres.

Poor health indicators were also evident indisparities depends on poverty. Income poverty wasassociated with poor health outcomes. Data derivedfrom the 2003 Demographic and Health Survey4

show that in the lowest socio-economic quintile,infant and child mortality rates were much higher(up to 50% higher) than in the richest quintile, andthe incidence of moderate and severe malnutritionwas almost four times greater. The financial barriersrepresented by user fees, which deter use of servicesby poorer people is a major contributor to inequalityto health services.

In contrast with other countries that havedefined a basic package, the focus of KEPH is not

4Central Bureau of Statistics,Kenya Demographic and HealthSurvey (KDHS), Key Findings, 2003.

2 Ministry of Health, Reversing the Trends: The SecondNational Health Sector Strategic Plan of Kenya – The KenyaEssential Package for Health, July 2007.3 Ministry of Health, Norms and Standards for HealthService Delivery in Kenya, June 2006.

Barriers to access to health care come in manyshapes – financial, social, cultural andgeographic. NHSSP II provided for action toimprove access in all these areas.

5

on delivery of a limited set of interventions, butrather on the delivery of a comprehensive packageof services aimed at keeping the population in Kenyahealthy, and so able to contribute to the economicdevelopment as outlined in the Government’smedium- and long-term development strategies. TheKEPH emphasizes provision of services using athree-pronged approach, covering three maindimensions needed to maintain health:w Improving lifestyles – that is, encouraging

healthy behaviour.w Preventing disease – that is, ensuring the

population is able to avert avoidable diseases.w Curing illness and rehabilitation – that is,

ensuring that those who get ill are appropriatelytaken care of.

This KEPH approach forms the basis of theService delivery reforms initiated with NHSSP II.While appreciating that service delivery reforms needa longer period than two years to show impact, it isimportant at this stage to review whether the sectoris moving in the correct direction, and if appropriatepolicy direction is being provided to enable suchmovement.

The shift to the KEPH has still not taken rootin the sector. Services are still largely curative. Evenwith the key preventive divisions, the modificationof their strategies to take into consideration the needto address interventions using the KEPH philosophyhas not yet fully occurred. As a result, interventionsto service delivery units are still highly fragmented.This is seen even in areas that the sector has definedas priority. For example, while the sector hasdefined the comprehensive community approach,many programme areas are still implementingvertical community approaches. Implementationunits therefore have to grapple with a comprehensivecommunity approach, and community approachesfor key programme areas like TB, integratedmanagement of childhood illness (IMCI), maternalhealth, HIV, etc. This is confusing and fragmentingto implementation units.

Progress with Implementation inLine with KEPH

As the Midterm Review is based on servicedelivery information for the first two yearsof NHSSP II, without including the final

six months of the actual midterm, targets are basedon 40% of the overall NHSSP II targets, and notthe 50% as expected. Although most of the indicatorsdo not have both NHSSP II and MTR targets, thetrend over the AOP 1 and AOP 2 periods, in mostcases, is positive. In most of the indicators wherethere is specified target, the sector is either aheador on target to meet the NHSSP 11 outcome targets.

The positive outcomes of the services providedin the last two years are expected to positivelyinfluence the health status, which can only beverified when the next KDHS is published.Achievements so far for each of the cohorts, basedon support so far in enabling reversal of trends, arenow highlighted.

Table 2.1: Status of indicators against reviewtargets

Benchmarks for Number of sectorreviewing indicators that performedprogress Below target On target Above target

Expected onJune 2007 (40%) 4 1 6

MTR target 2 0 5

Cohort 1: Pregnancy, Delivery andthe Newborn

Prior to NHSSP II, the sector had seen worseningof output indicators for this cohort. Availability anduse of services for this cohort was a noted weakness.Even in areas where services were available,utilization was limited by a mix of supply side(availability of staff and equipment) and demandside (socio cultural issues) issues. The services tothe cohort, together with cohort 2, were priority forimplementation in AOP 1, with scale up of priorityinterventions expected in AOP 2. But the first twoyears of the NHSSP II have produced a mixedpicture. Performance so far has been good for two ofthe three results in this cohort, with poorperformance for the result of “Mothers are able tohave normal deliveries”. Targets on WRA receivingfamily planning commodities and HIV-positivepregnant women receiving treatment for preventionof mother-to-child transmission of HIV (PMTCT)are more than achieved. On other hand,achievements in the area of delivery services,distribution of insecticide bed nets (ITNs) topregnant mothers and antenatal care (ANC) servicesare below target (Table 2.2). This implies, much asthe sector is ensuring safety in pregnancy, mothersare still at risk, as the delivery processes are stillnot adequate. It should be noted that most of thematernal mortality is a result of events at delivery.

As can be seen from Figures 2.1–2.3, only 80%of the expected results as of June 2007 was realizedin ANC services. There is a decline in ANC provi-sion from AOP 1 to AOP 2. While this needs to beexplored further, since the four visits were intro-duced during AOP 1, the data on performance reportof AOP 1 might have been a mixture of two andfour visits, which overstate achievement at the time.

This achievement is even lower in deliveryservices as the sector realizes only 60% of the

6

expected result. It is important to note that eventhough the trends represented in Figure 2.3 seemto show that the sector is performing even lowerthan the baseline, this is because of the differentdata sources used. While the baseline was based onthe population based survey (KDHS 2003), theprogress reported is based on routine information.

On the other hand, in the area of family planning,96% of MTR targets and 40% more than the expectedtargets by June 2007 has been achieved. While thesector was able to distribute 2.8 million nets forunder-five children (see next cohort) during AOP 2,this was limited to only 445,000 for pregnantwomen.

The sector interventions in the first two yearsof NHSSP II have focused on ensuring that supply-side issues are addressed. Supplies at facilities haveimproved to enable delivery of maternal health

services, in line with implementation of the“Roadmap to Maternal Health”(Reference # 6).Addressing the demand-side issues, ensuringservices are appropriately tailored to expectationsof the communities, has been limited to a few pilotareas, particularly in Nyanza Province. Delay inroll out of the community approach in the sectorhas played a role in the inappropriateness withwhich the demand side issues are addressed.

As such, how well the progress made in this

Table 2.2: Achievements of targets for cohort 1

Indicators NHSSP II Targets Achievement Remarksbaseline Expected MTR AOP 1 AOP 22004/05 June 2005 targets

% WRA receiving familyplanning commodities 10% 30% 45% 13% 43% AT

% ANC clients (4 visits) coverage 54% 64% 56% 52% BT% Deliveries conducted by skilled

attendant in health facilities 42% 61% 18% 37% BT% Newborns with low birth weight

(less than 2,500 g) 2% 6%% HIV+ pregnant women receiving

Nevirapine (PMTCT) 10% 26% 90,985 29% AT# LLITN distributed to

pregnant women 55,000 362,345 445,497% ANC clients receiving IPT 2 4% 44% 40%# Health facilities providing basic

emergency obstetric care (BEOC) 9 12 646# Health facilities providing

comprehensive emergencyobstetric care (CEOC) 203

No. of maternal death audits 178

04/05 07 PERFORMANCE BYJUNE 07

ACHIEVEMENT ACHIEVEMENT

Period

54%

64%

56%

52%

0%

10%

20%

30%

40%

50%

60%

70%

NHSSP II B/LINE MIDTERM TARGET EXPECTED AOP 1 AOP 2

Per

cen

tag

e

Figure 2.1: ANC client coverage (4 visits),percentage

42%

61%

18%

37%

0%

10%

20%

30%

40%

50%

60%

70%

NHSSP II B/LINE 04/05

MIDTERM TARGET 07

EXPECTED PERFORMANCE BY

AOP 1ACHIEVEMENT

AOP 2ACHIEVEMENT

Period

Per

cent

age

Figure 2.3: Percentage of deliveries conductedby skilled attendant in healthfacilities

Period

10%

45%

30%

13%

43%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

NHSSP II B/LINE MIDTERM TARGET EXPECTED AOP 1 AOP 2

Per

cen

tag

e

Figure 2.2: Percentage of WRA receivingfamily planning commodities

7

cohort will go in reversing outcomes and impact ofhealth of this cohort is not clear. A clear analysis ofthe impact of the different demand and supply sideissues is needed, to guide investment in each of thesethat is appropriately balanced to give the appropriateimpact. Interventions in the remaining years of theNHSSP II therefore need to focus both on scalingup supply side (re-open closed health facilities,improve delivery infrastructure, and trainworkforce), and on strengthening demand sideissues through appropriate implementation of thecommunity approach. This ensures views and inputfrom the clients is incorporated in the delivery ofservices.

Cohorts 2 and 3: Early and LateChildhood

The services towards cohort 2 (early childhood) werea priority in AOP 1, with scale up expected in AOP2 as with services for cohort 1. A series ofinterventions was carried out that will yield goodimpact for this cohort. These included push for scaleup of routine immunization, child and maternalhealth and nutrition weeks, mass scale up ofinterventions to reduce malaria in children,particularly in case management (ART use), andvector control (IRS spraying), plus ITN use amongstchildren. Figures 2.4 and 2.5 illustrate the progressin immunization coverage.

ITN coverage has increased rapidly in Kenyasince 2004. During AOP 2, close to 5 million ITNswere distributed to children under-five. The extentto which this investment has led to improvements

in child survival has not been analysed through astudy a dynamic cohort of approximately 3,500children aged 1–59 months enumerated each yearfor two years in 72 rural clusters located in four

Table 2.3: Achievements of targets in cohorts 2 and 3

Indicators NHSSP II Targets Achievement Remarksbaseline Expected MTR AOP 1 AOP 22004/05 June 2005 targets

% Children < 1 yr immunizedagainst measles 74% 82% 94% 67% 80% BT

% Children < 1 yr fully immunized 58% 75% 78% 59% 80% AT% Newborns receiving BCG 84% 88% 96% 99% AT% Children <5 attending CWC and

found underweight 9% 11%% Children <5 attending growth

monitoring services (NEW VISITS) 20% 61%% children <5 receiving Vit A supplement 33% 45% 15% 34% BT# LLITNS distributed to children under

5 yrs 250,000 1,739,675 2,773,293# under five years treated for malaria 2,514,504% of health facilities providing treat-ment as per IMCI guidelines 2% 10% 12% 9% 15% AT# Districts with community IMCI

interventions 50Late childhood (6 to 12 years)% School children correctly de-wormed

at least once in the planned period 25% 47% 5% 43% BT# Schools having adequate

sanitation facilities 86,771

74%

94%

82%

67%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NHSSP II B/LINE04/05

MIDTERM TARGET07

EXPECTED PERFORMANCE

AOP 1ACHIEVEMENT

AOP 2ACHIEVEMENT

Period

Per

cent

age

Figure 2.4: Children <1 year immunizedagainst measles (%)

Figure 2.5: Children <1 year fully immunized (%)

58%

78% 75%

59%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

NHSSP II B/LINE04/05

MIDTERM TARGET07

EXPECTED PERFORMANCE BY

JUNE 07

AOP 1ACHIEVEMENT

AOP 2ACHIEVEMENT

Period

Per

cen

tag

e

8

districts of Kenya. Initial indications from the ITNpost mass distribution survey indicate theintervention was pro-poor, with uptake much higheramongst the poorer segments of the community.This is the segment most affected by illness,suggesting improvements in malaria morbidity andmortality. Net use increased from 7% at the firstenumeration round to 67% at the last enumerationround and ITN use was associated with a 44%reduction in mortality.

In the last two years not only the coverage ofITN distribution for children under-five increased,but also the distribution of these nets have becomemore pro poor. as can be seen from Figure 2.6, accessto nets has increased by the most poor, very poorand the poor during the three years presented. Thiswas achieved as a result of a shift in the mode ofdistribution of ITNs from retail to mass freedistribution which ensures universal coverage.

In 2001, 68% of the nets were distributedthrough subsidized retail outlets and a marginal8% was through GOK/Mission clinics and there wasno free distribution. In contrast, in 2007, about 45%of net distribution was carried out through massdistribution. The impact of this is an improvedequitable distribution and use of nets by childrenas presented by the Lorenz curve (Figure 2.7). Ascan be seen from the curve, in 2004/05, distributionand utilization of nets was not equitable as the linefor the year is lower than the equitable linerepresented by the dotted line. But the line shiftsupwards reflecting the fact and become above thedotted line showing that more of the poor aresleeping under the net.

The IMCI health facility4 survey carried out in2006 showed the common illnesses at facilities wereacute respiratory infections (ARI), malaria, anddiarrhoeal diseases. Malaria is the main cause ofmorbidity and mortality to children, and thereforeposes a major risk. Therefore, interventions inmalaria control should help the country reversetrends in child and infant health.

Despite the impressive achievement in malariacontrol during the two years, Kenya is still far fromachieving the Abuja targets (see Figure 2.8). Thereis need, therefore, to scale up the implementationof malaria control interventions.

Nevertheless, interventions for child health arenot being addressed holistically. Differentprogramme areas are addressing differentcomponents of child health. The immunizationprogramme, Division of Child Health, and Divisionof Malaria Control are all offering key interventionsfor child health, which are not adequatelycoordinated. The KEPH concept of packaging

services along cohort lines for better planning andmanagement of services are yet to be fully practiced.The sector is therefore not clear on the impactsuccesses in selected intervention areas are havingon reversing the high mortality of children. Theimpact of displaced mortality – from the cause ofmortality being addressed to other causes ofmortality – is not clear. For the sector to thereforeadequately reverse poor child health outcomes, itneeds to holistically address child health issues; withinterventions across the major causes of childmorbidity and mortality being concurrentlyaddressed.

Figure 2.7: Lorenz concentration curve forchildren using ITNs, 2004–2007

Figure 2.8: Progress against Abuja targets inKenya 2001–2006

4% 5% 4% 5%

52%

20% 14%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ITN use in children under 5

Yrs

IPT coverage Access to prompt and effective

treatment <24 hours

ITN use in pregnant women

2002 2006

Figure 2.6: Use of ITNs by wealth quintilefollowing mass distribution, 2004–2007 in Kenya

4 MOH and National Coordinating Agency for Populationand Development, IMCI Kenya – Integrated Management ofChildhood Illness Health Facility Survey Report, 2006.

9

Cohort 4: Adolescence

Services to this cohort have been scaled upsignificantly during the first two years of NHSSPII, with a growing number of facilities now offeringyouth-friendly services – from 5 facilities in 2004/05 to 86 in June 2007. This doesn’t form the fullextent of expected services for the adolescent cohort,and, as noted in the AOP 2 report, the full packageof services is too costly for most facilities, leadingthem to implement it piecemeal.

Yet, much as there has been some recognitionof the need to tailor services to this cohort, interven-tions so far offered are not able to turn the trends inhealth for the adolescents. A more comprehensivebut cost-effective focus on this cohort is needed.

Cohort 5: Adult/All Life Cohorts

Varied services are offered for this cohort, represen-ting a wide scope of interventions across the sector.Services were scaled up during the first two yearsof NHSSP II for most of the major causes of illhealth, particularly HIV/AIDS, TB and malaria. SeeTable 2.4.

In HIV, information is suggestive that therewill be reversal of trends by the end of the NHSSPII period. HIV prevalence among adults has reducedfrom 6.7% in 2003 to 5.1% in 2006. The trend seen,however, had commenced prior to the NHSSP II(Figure 2.9). As such, interventions in the NHSSPII have built on those started in NHSSP I to lead toreductions seen in HIV prevalence.

Table 2.4: Achievements of targets in cohort 5

Indicators NHSSP II Targets Achievement Remarksbaseline Expected MTR AOP 1 AOP 22004/05 June 2005 targets

# HIV+ patients started on ART 8,000 65,502 164,827# VCT Clients 200,000 474,899 780,261# New outpatient (curative) visits 0.08 0.4 22,572,807# over five years treated for malaria 4,824,691Malaria inpatient case fatality rate 26% 9,028Total # of hospital admissions 799,874# Condoms distributed (million) 80,000,000 43,950,000 46,122,511# TB cases detected 47% 50% 70% 0.331 71,177TB cure rate 67% 70% 82% 75% 24,133TB treatment completion rate

(Sputum+/DOTS) 80% 83% 85% 83% 22,789 DQ# of Districts with functional DHSF 54# Trained Village Health Committees

(model VHC) 1,840 1,906Number of CHWs trained 5294Number of functioning community

health units 129# Houses sprayed with IRS 2,500 443575 514714Total number of beds 47,555# Occupied bed days 5,748,034Total number of OPD attendance 32,974,232

Source: Routine reports.

4.6%5.1%

6.7%

0%1%2%3%4%5%6%7%8%9%

10%

2001 2002 2003 2004 2005 2006

Weighted ANC Trend

Figure 2.9: Adult HIV prevalence, 2001–2006

Source: HIV/AIDS Statistics 2007.

The provision of ART services have led to asignificant reduction in mortality associated withHIV/AIDS (Figure 2.10). In spite of this, the numberof new infections has stabilized at 55,000 per year.This implies available mass strategies are reachingtheir saturation point, with further reductions inincidence requiring additional interventions that arebetter targeted at the vulnerable populations. Aswith HIV, key scale up of other interventions,particularly as regards the TB and malaria weredone. Scale up of TB control initiatives has markedlyimproved, leading to improvement in TB outcomes.The trends in TB incidence are negative, with areduction of 9.2% between 2005 and 2006. The TBcase detection rate is higher than was targeted, atover 70%. Treatment success rate is also highcompared with the target, though there are stillhigh defaulter rates. TB DOTS, and collaborativeTB/HIV activities are now in place across the

10

country, despite constraints in terms of humanresources, infrastructure and financing needed toefficiently operate these interventions. Theseconstraints are also affecting the programmaticmanagement of multi drug resistant (MDR) TB,scaling up of community-based TB care, and othernew initiatives to manage the TB burden. Impactinformation on malaria interventions was alreadyhighlighted in relation to children. Theseintervention areas saw scale up of services acrossthe country, owing to the availability of significantpartner resources that could be more targeted tothe cost effective conditions within these threeconditions. In addition, other non-traditional areasof interventions had services being scaled up. Assuch, interventions relating to management of non-communicable conditions, for example with tobaccocontrol, were implemented in the first two years ofthe NHSSP II. All these interventions should affectthe burden on ill health and death in this cohort.

Most of the services represent scale up oftraditional interventions, as opposed to realigningscope of interventions across the KEPH services.Interventions are still provided with minimallinkages across areas representing a coordinatedeffort towards improving health of this cohort. Aswith Cohort 2, the extent of shifting morbidity andmortality, to areas not being addressed is not clear.As such, it is difficult to estimate the impact of allthe interventions on overall reversal of trends forthis cohort. Indications of interplay of morbidity andmortality are for example seen in the dual HIV/TBmorbidity and mortality. While interventions in HIVarea have reduced incidence and prevalence of thecondition, the inadequacy in implementation ofinterventions addressing TB burden is contributingto a significant amount of morbidity and mortalityeven in HIV positive clients. Interventions to addressboth TB and HIV are now being scaled up acrossthe country.

Some indications are pointing in the directionof improving health. Reductions in inpatient casesand deaths could indicate a reduction in severity ofillness in this cohort. Further analyses are needed,to generate an appropriate package of services that

need to be implemented together, to affect the healthof this cohort. The present focus on the ATM set ofconditions needs to be backed up with interventionsin other major causes of poor health in this cohort.

Cohort 6: Elderly

The sector has not yet focused services for this cohort.Interventions received by the cohort are part of thestandard services provided for the all life cohort.Interventions for appropriate ageing are planned forthe different cohorts, which will affect their healthwhen they reach this cohort. For those already inthis cohort, there is need for specific services thataddress their health needs. As such, the sectorcannot yet talk of reversing trends for this cohort.There is need to urgently review requirements forthis cohort, and plan a cost effective mechanism fordelivery of defined services to it.

Progress with Implementation ofStrategies to Improve Access

Results to date have been achieved through aconcerted effort of implementing variousstrategies, ranging from strengthening

community interface to improving the productivityof health workers. The strategies used in the lasttwo years, the challenges faced and actions requiredto strengthen the gains are described below.

Improving Geographical Access

A number of strategies addressing the geographicalbarriers to accessing health care were planned tobe undertaken during the implementation of thisstrategic plan. These are described below.

Strengthening Interface between Services andCommunityIn 2006, the MOH approved a Community Strategy5

that aims at directing support to promote healthand to prevent ill-health in the communities. Thestrategy proposes empowerment of communities toadopt health life styles and strengthened linkageswith the formal health sector through communityheath workers which are supervised and supportedby community health extension workers. To datethe community implementation guidelines, keymessages and training manuals for the communityhealth extension workers and the community healthworkers have been developed. These managementand operational guidelines and manuals lay a solid

Figure 2.10: Estimated deaths averted because of ART scale up

83,000

115,000

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

1990 1995 2000 2005

Deaths Averted ART No ART57,000 deaths averted by ART programme

Source: HIV/AIDS Statistics 2007

5 Ministry of Health, Taking the Kenya Essential Packagefor Health to the Community: A Strategy for the Delivery ofLEVEL ONE SERVICES, April 2006.

11

foundation that is necessary for effectiveimplementation and functioning of the communityhealth interventions. Training of central, provincialand district health teams in the management ofthe Community Strategy has been undertaken.

Training was provided for community healthextension workers and community health workers.In total, 274 CHEWS and 3,100 CHWs were trainedand deployed using the new guidelines. Pilotcommunity units have been established in Nyanzasince 2006. In 2006/07 FY, a total of 129 communityunits were established and became functional, ofwhich 78 are per the new guidelines. Thefunctionality and effectiveness of these units havenot been reviewed. It is necessary to learn theinnovations and challenges faced in theimplementation process across districts as thisstrategy is being implemented on ‘learning by doing’basis. The implementation process is expected tomove a step forward when the health systemsstrengthening programme supported by GAVI isimplemented during AOP in selected districts.

The Community Strategy has also an inbuilthuman rights approach by ensuring that level 1services meet the needs and priorities of all cohortsand socioeconomic groups, including the “differently-abled”, and strengthen the community to progress-ively realize their rights to access quality care andto seek accountability from facility-based healthservices. The human rights approach for health willbe used as a tool to empower those who are not in aposition to assert and defend their claim to equitablequality health care. This intention has not yet beenimplemented but is in the process of being rolledout. The divisional dialogue days in the pilot commu-nities units are used a mechanism for communitiesto claim their rights (quality of care, waiting timeand attitude of staff) for service providers.

Interface between the formal health system andthe community is being strengthened throughcommunity participation in the coordination,planning, managing and monitoring of healthservices. A number of forums have been set up fromthe village to the provincial level to foster thisownership, including village health committees(VHC), Health Facility Committees (HFC), DistrictHealth Management Boards (DHMB), DistrictHospital Boards (DHB), Divisional and DistrictHealth Stakeholders Forum (DHSF) and ProvincialHealth Stakeholders Forum (PHSF). While it canbe appreciated that these governance structures arewell defined in the JPWF and these structures havebeen put in place, the degree at which thesecommittees functions varies across communities,facilities, districts and provinces. As such, there isa need to build their capacity and understanding oftheir roles and responsibilities.

The implementation of the strategy tostrengthen the interface between the communityand the lowest level of the health system is in itsearly stages and has limited coverage. Even so,

significant progress has been made in rolling outthe Community Strategy. The ideals and principlesof NHSSP II regarding the implementation of levelone services was translated into operational modethrough the Community Strategy document. Thestrategy defined what services are to be provided atthe community level and the type of humanresources required implementing such a service. Themodality of implementation of the CommunityStrategy was also defined in its implementationframework.6 These two documents provide the policyframework for the implementation. These neededto be supported by practical and user-friendlyguidelines that help district and communitymanagers in implementing the strategy.Subsequently, three implementation tools7 weredeveloped and used.

Providing health services to a nomadicpopulation in vast areas with few health facilities,poor roads and limited transport from a health caredelivery system designed for a sedentary populationhas been a challenge which is the case in the NorthEastern Province and other arid and semi-arid areasin the country. MOH has therefore introduced threepilot nomadic clinic as one way of bringing basichealth care services closer to the nomadic populationliving and moving around in the non-serviced areasof NEP. Further testing and roll out withdocumentation of results is required in order todetermine that the sector is on the right track.

Expansion of Network of Health Facilitiesthrough Construction and RehabilitationThe MOH’s capital investment policy should focusis on rehabilitation of existing facilities, providingnecessary equipment, establishing functionalreferral system on the basis of established normsand standards for human resources, equipment,transport and infrastructure. In the detailedImprovement Plan for Infrastructure (April 2006),there are plans to construct 169 new dispensaries,to upgrade 238 dispensaries to health centres, andto upgrade four health centres to district hospitals,with a preponderance of the new and upgradedfacilities being located in remote and currentlyunder-served areas. To this end, MOH has beenallocating financial resources for maintenance andrehabilitation of health facilities and for purchasingequipment. During AOP 1, 1,668 dispensaries, 475

6 Ministry of Health, Community Strategy ImplementationGuidelines for Managers of the Kenya Essential Packagefor Health at the Community Level, March 2007.7 Ministry of Health, Enhancing Community Health Systems– Partnership in Action for Health: A Manual for TrainingCommunity Health Extension Workers; LinkingCommunities with the Health System: The Kenya EssentialPackage for Health at Level 1 – A Manual for TrainingCommunity Health Workers; Key Health Messages for Level1 of the Kenya Essential Package for Health – A Manual forCommunity Health Extension Workers and CommunityHealth Workers, March 2007.

12

health centres and 16 rural Health Training andDevelopment Centres were renovated.

As a result of infrastructure improvements, thenumber of sites offering basic services haveincreased (Table 2.5 and Figure 2.11).

Table 2.5: Infrastructure improvements

Service expansion 2004/05 2005/06 2006/07

Basic and comprehen-sive OC 9% 12% 17%

Number of VCT sites 682 859 908No of facilities offering ART 222 303 358No of facilities using

IMCI guidelines 2% 9% 22%Facilities offering youth-

friendly services 5 73 86

Source: Routine reports.

This rational and restrained buildingprogramme is in danger of being disrupted by theuncoordinated construction of dispensaries usingConstituency Development Funds, which MOH isthen expected to operate. There are anecdotal reportsthat up to 1,600 such dispensaries have been built,not necessarily to appropriate designs and standards,or in appropriate locations – this may be determinedon political grounds as opposed to rationalization ofaccess. Currently, 300 of these CDF constructedfacilities have been reopened and are functioning;in FY 2007/08, an additional 600 dispensaries willbe operational.

The expansion of network of health facilitiesthrough the CDF needs to be integratedharmoniously, together with other required inputs(especially human resources, drugs, etc), to ensureefficient, equitable, effective and sustainable deliveryof health care services. This can be achieved if theCDF infrastructure work is well coordinated andthat the MOH is fully involved in the planning andimplementation of the CDF projects. This fund canmake a significant impact in terms of reversing thetrends if it supports the priorities defined and agreedin district health stakeholders. The consultationinitiated with the CDF Committee needs to befurther strengthened and result in mechanisms on

how the fund supports sector priorities and theirinterventions be part of the health sector overallplan and budget.

The current infrastructure norms andstandards for the KEPH are based on populationsand do not take into account of distances travelledby clients. Yet the 2007 Client Satisfaction Surveyshowed that respondents seeking outpatient servicesin hospitals live further away (over 13 kilometres)compared with those seeking services in healthcentres (7 km) or dispensaries (4 km). The overallaverage distance that patients/clients must travelto reach any type of facility is about 9 km. There istherefore a need to establish additional new facilitiesparticularly in hard to reach areas.

Increase in Number of Health Workers inFacilitiesThe availability and comprehensiveness of healthservices offered at a health facility depends on thenumber of health workers at that facility. TheJPWF estimates that approximately 427,000 healthworkers are needed to deliver KEPH, of which321,000 comprise the CHWs operating at level 1 onvoluntary basis. The formal human resourcerequirement for the sector is estimated at 106,000against 62000 in post. This gives the formal humanresource gap of 44,000. It is planned that 50% ofthe shortfall (22,000) will be bridged during theNHSSP II period, and priority will be given to thedeployment of staff to hard-to-reach areas.

Since 2005 there has been a concerted effort toincrease the number of skilled health workersavailable at the lower level of the health systemusing government funds and ear marked funds (forwhat is known as emergency recruitment) fromfoundations and global initiatives. The staffrecruited through the emergency recruitmentarrangements are on three-year contracts and thereis agreement that the newly recruited on contractswill eventual be absorbed onto the MOH payroll.Table 2.6 shows the number of health workersrecruited and deployed mainly in the public healthfacilities during fiscal year 2006/07. Against thetarget of 4,000 health workers, 3,649 have beenrecruited to date.

The supply of health workers appears adequateto meet the increased staffing requirements. Theoutput from the training institutions is increasingand there are a significant number of applicationsfor government positions.8 Although initially the2006 emergency recruitment process attracted asubstantial number of applications (20%) fromhealth workers employed in FBO facilities, themajority (71%) of those short-listed were in factunemployed health workers.9 This was achieved

8 There were 1,876 applications received by the PSC for 150KECHN III positions.9 World Bank, “Preliminary analysis of the USAID/CAPACITY Emergency Recruitment Data”, 2007.

27 28

37

50

60 62

0

10

20

30

40

50

60

70

YEAR

% C

OM

PL

ET

E R

AT

E

HF complete rate 27 28 37 50 60 62 Year 2001 Year 2002 Year 2003 Year 2004 Year 2005 Year 2006

Figure 2.11: National health facilitycompletion (%), 2001–2006

Source: HMIS.

13

through good recruitment practices and effectivecontrols, which also mitigated the risk of increasedmovement and migration within the sector andgreater distribution imbalances.10

There will be a greater demand for education,training and development initiatives to matchincreased staffing levels and to equip the healthworkforce with new and relevant skills to deliverthe KEPH. Improving the capacity of provincial anddistrict level managers in areas such as leadership,management and supervision will also be requiredto enhance the delivery of the KEPH and roll out theresults-based management approach. With the theCommunity Strategy in place, large numbers ofCHEWs and CHW will be recruited who will requireretooling in areas such as health interventions,supervisory support, and performance monitoring.

Policy implications: The recruitment of staff tofill vacant posts and/or meet additional require-ments is dependent on the availability of funds (PEceilings) and the number of approved posts(establishment). Any request for recruiting staffmust be approved by DPM and funds should bereleased by Treasury. The current number of MOHestablished posts is 44,813 (this excludes non-publicservice providers), and current number of fundedposts is 35,627.11 Although there is no official recruit-ment freeze and the MOF is more flexible with thefunding of PEs for social sector ministries, thereare still tight controls on the PE budget. The sectorneeds to negotiate with Treasury for approval ofresources to fill 9,000 workers in the approved posts.

Strengthening of Referral System between theVarious Levels of the Health SystemThe referral system between various levels is beenstrengthened through improving the effectivenessof the communication and ambulance system.

Usage of mobile phones for referral purposes hasbeen introduced in health facilities. One hundredand eighteen ambulance vehicles (118) have beenprocured and distributed to health facilitiesthroughout the country. The draft referral guidelinebeen developed. There need to conclude theguidelines and initiate the implementation of thecomprehensive referral services, inclusive of a sectorICT implementation plan, transport policy andmaintenance policy.

Improving Financial Access

The intention to shift the allocation of resourcesbetween levels of the system in favour of levels 1–3has a pro-poor intent and is expected to result inexpanding access to the most geographicallydispersed and affordable units of the provider system;the main beneficiaries being the rural population,among whom the poor are over represented

Poverty is one factor employed in weighting thedistribution of funds to rural health facilities. Thebasic approach is to allocate funds among districtspro rata with population, weighted for poverty, AIDSincidence, female population of reproductive age,number of government facilities, child populationand density. The pro-poor effect of this distributionis much weakened by the inclusion of otherweighting factors, and the small proportion of therecurrent budget (just over 2%) to which it applies.The positive pro-poor effect of this formula is totallyswamped by two other distributions. The firstrelates to the operating costs of hospitals, for whichthe distribution formula is heavily weighted byinpatient and outpatient numbers (reflecting theinitial inequitable distribution of installed capacity).The second is that for PEs, which make up nearly75% of total recurrent cost, the money is attachedto the bodies and not to the place in which they areserving. Since the actual deployment of personnelis heavily skewed in favour of hospitals and thericher districts, this means that the overall

Table 2.6: Staff recruitment 2006/07

Cadre GOK PEPFAR/ Clinton Global TotalCapacity Foundation Fund recruitment

2006/07

Enrolled C Nurses 300 (ECN III) 450 723 391 1,864Registered Nurse 63 325 15 403Nursing Officer 100 85 185Clinical Officer 130 44 106 81 361Pharm Technologists 80 36 12 128Lab. Technologist 60 98 30 188Social Workers 18 18VCT counsellors 230 230Health Records Officers 39Accountants 80 80Data clerks 153 153Totals 670 591 1,154 1,093 3,649

Source: JSP 2007.

10 Samuel Mwenda, “Looming human resource crisis inmission health facilities in Kenya”, 2007.11 MOH, “Health Sector Establishment HRM Records Unit”,2006.

14

distribution of GOK funding is similarly skewed infavour of those areas. Revision of RAC was plannedbut not implemented.

Another source of inequitable access is thefinancial barriers represented by user fees, whichdeter use of services by poorer people. In theory,some mitigation of the deterrent effect of usercharges is afforded by exemption and waiver policiesapplicable in public (and some FBO/NGO) facilities,but there is little evidence to suggest that thesepolicies are applied as frequently as the necessityimplied by the poverty statistics. In an attempt toreduce the burden of out of pocket payments at thelevels 2 and 3 of the public health system, the 10/20policy was introduced in 2004. Under-five ANC,Malaria, TB and HIV/AIDS, amongst others areexempted services. In addition, the MOH hasrecently introduced a policy to provide facility baseddelivery services.

The introduction of 10/20 had an immediateeffect of increasing access but the increases werenot sustained at initial levels because of thereduction in quality of care resulting from the lossin funding to finance supplementary drug and non-medical supplies, pay for support staff and payallowances for staff outreach activities.12 The MOH,with development partner support, is piloting directfacility funding (the Health Facility Fund – HFF13)in an effort to redress this loss of income to the healthfacilities.

MOH and development partners are also work-ing on a number of other pilot projects to increaseaccess through addressing financial barriers toaccessing care. These include social franchising andsocial marketing on the supply side and patientvoucher and fee waiver systems on the demand side.

There is need to review pilot schemes on user/patient financing through output based aidmechanisms, to assess the feasibility for scaling upthese schemes. Further work need to be undertakenon fee waiver refund schemes and on standardizingfee waiver criteria.

Addressing Social-Cultural Barriers

Increasing demand for the KEPH through removalof socio-cultural barriers will be achieved throughthe implementation of the Community Strategy. TheCommunity Strategy, already developed, tends toachieve this through increased health promotionand BCC activities. The communication strategyaddresses social values and attitudes that influencehealth seeking behaviour. FGM strategy is preparedand being implemented.

Summary of the MajorRecommendations

Many recommendations have come out ofthe MTR process from the internal review,IRT report and the stakeholders meeting.

These recommendations are summarized below.

Recommendations for strengthening the roll out anddelivery of the KEPHw Accelerate implementation of the following areas

of focus of the KEPH: Safe motherhood,Community Strategy, Malaria, TB and NCDs,

w Sustain ongoing service delivery interventionsin the areas of focus that have performed wellduring the period under review.

w Develop implementation frameworks forproviding services to cohorts 4 and 6.

Recommendations for addressing barriers toequitable access to health servicesw Undertake a Practice and Policy review to

develop appropriate policy frameworks forinfrastructure, health facility plant, equipmentand transport as well as for ICT including aftersale maintenance policies.

w Continue dialogue with CDF Committee toensure that the fund is supporting sectorpriorities and its contribution is integrated atdistrict and national sector plans and budgets.

w Develop and implement registration guidelines,standards and regulations for the operation ofhealth facilities with a clear separation ofresponsibilities of managing health facilityoperations or implementation of service delivery.

w Review innovative service delivery mechanisms(like the NEP nomadic clinic and others) forimprovement and scaling up services to remotehard-to-reach areas

w Negotiate with Treasury to get approval ofresources to fill the 9,000 approved posts, andwith donors to assist in financing them.

w Finalize the referral guideline, initiate theimplementation of the comprehensive referralsystem that is guided by an ICT and transportpolicies and strategies.

w Undertake further reallocations of publicfunding towards pro-poor programmesespecially rural health services in light ofcurrent poverty levels that justify more waversof facility fees to alleviate financial constraintsto health services access by the poor.

w Expedite improved direct financing of facilitiesto help make good of the revenue loss fromexemptions, wavers and recent abolition of feesat lower levels of care.

w Make the Community Strategy even moreinclusive by bringing on board all interestedparties and resolving issue on terms ofconditions of CHWs.

12 Major finding of survey commissioned by MOH of theimpact of introducing the 10/20 policy.13 MOH Position Paper on Health Facility Fund, July2006, and Danida HSPSII Programme Document,September 2006.

15

3. Progress with Objective 2: ImprovingService Quality and Responsiveness

Key elements of service quality are theperformance of the service providers andthe responsiveness to client needs.Efforts to improve both these areas are

fundamental elements of objective 2 of NHSSP II.

Improving Health WorkerPerformance

Health care worker productivity is a keyingredient for improving quality of healthservices. Given the staffing shortages it is

critical that performance and productivity of theavailable workforce is effectively managed andsupported. A number of initiatives have beenundertaken to improve health worker performanceas detailed below.

The MOH has taken the first steps towardsintroducing and institutionalizing results-basedmanagement (RBM), a government wide publicsector reform initiative, as an approach for effectiveimplementation of the NHSSP II and its respectiveAOPs. Performance monitoring, performancecontracting and Rapid Result Initiative are the mainforms of RBM adopted by the Ministry.

Quarterly reporting and review processes havebeen instituted by the Permanent Secretary, inwhich District, Provincial and HQ performance isreviewed against AOP indicators/targets. Theanalysis and processing of reports is carried out bythe Ministerial Management Unit (MMU), a unitset to coordinate performance monitoring of thesector, and performance review is undertaken bythe Permanent Secretary’s senior managementteam. The PS, PMOs and DMOHs are heldpersonally accountable for performance through asystem of performance contracts.

Performance contracts are a key feature of thenew way of working in the Ministry of Health. All

key senior staff at the central level, MedicalSuperintendents, PMOHs and DMOHs haveperformance contracts. The use of performancecontracting at lower levels has the potential toimprove quality of care, if such targets areappropriately expressed in these contracts.

The challenge of the RBM is to relate the resultsspecified to resources, which will involve thedevelopment of programme budgeting. Thisdevelopment will depend on progress with the publicfinancial management reform programme.

The Government has approved for implemen-tation, a new Performance Appraisal System (PAS)for the public service. This system will support thestrengthening of performance management systemsat facility and individual levels. Support will berequired to effectively introduce and institutionalizethe PAS at all levels.

Three rounds of Rapid Results Initiative (RRI)have been undertaken to date. The priority areasfor the RRI have been immunization, TB, malaria,HIV/AIDS, SWAp and reproductive health. Thisinitiative has produced tremendous improvementin achieving results. In addition, achieving desiredresults, the initiative has produced the followingbenefits: building teamwork; improving planningand monitoring of performance; increased workersatisfaction through achieving results with theavailable resources. During the AOP 2 period, 12training hospitals take on themselves to reduce thewaiting time in both outpatient and emergency

The rapid results initiative has producedtremendous improvements in teamwork;planning and monitoring of performance; andworker satisfaction. A service charter introducedin 2007 recognizes the community ascustomers with rights and as claimants withlegitimate demands on the health services.

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Table 3.1: Reduction in waiting time in hospital RRI

Province Waiting time in outpatient department (days) Waiting time in emergency/surgical unitBaseline Target Decrease by Midterm Baseline Target Midterm

in 100 days decrease 100 days decrease

PGH KK 120 80 40 660 490 170PGH KSM 268 61 207 39 1125 281 844 480PGH NKR 360 240 120 30 240 120 120 90PGH Embu 177 150 27 360 60 300 285PGH Nyeri 0 0 0 0 0 0PGH Garrisa 131 90 41 36 120 60 60 30PGH Coast 360 240 120 105 328 224 104 219Kisii DH 105 85 20 5 1853 1714 139 685Machakos DH 0 0 0 0 0 0Meru DH 150 120 30 52 200 150 50 12Thika DH 450 300 150 210 840 420 420 120Kericho DH 300 180 120 120 570 180 390 270Kitale DH 360 240 120 270 480 240 240 120Total 2781 1786 995 867 6776 3939 2837 2311Average 213.9231 137.3846 76.53846 66.69231 521.2308 303 218.2308 0.418684

surgical units. The effort at mid-point of the RRIprogramme has managed to reduce the waiting timein outpatient department by 31% and emergencysurgical unit by 42%. The detail of the progress inhospital RRI is presented in Table 3.1.

Effective pay and compensation systems havebeen introduced to motivate health workers. Thesalary reviews which were effected by theGovernment in 2004/05 and 2005/06 have raisedthe average “take home” pay for senior managersin the civil service (Job Groups P, Q, R, S) by 200 –300%, for the middle level managers (Job GroupsK, L, M, N) by 100% while support staff (Job GroupA–J) received on the average 70% increase.

The role of supportive supervision is beingstrengthened through the development and use ofintegrated supervision checklists; this is hamperedin many districts, however, because of lack oftransport. There is growing use of clinical audits,and in a number of districts Maternal MortalityAudits are being used to identify problems in thequality of care at different levels.

A secure supply of drugs and commodities isessential in the delivery of health services. Thereare more drugs and commodities now in the healthfacilities than in the past, but there needs to be atracking system to confirm how much of theprocured items reach the intended beneficiaries.Procurement of drugs and pharmaceuticals underthe Procurement Consortium and by KEMSA (overthe last two years) is working well. In a number ofdistricts drug supply is moving towards a pull-system from a push-system; if effectivelyimplemented this has potential for improvingquality of care through increased supply ofappropriate essential medicines and medical supplies(EMMS).

Health worker performance can be improved ifthe health workers are satisfied with their workenvironment. The MOH Health Worker Satisfac-

tion Survey (2007) conducted to analyse the employeeand work environment satisfaction among the staffof the Ministry of Health deployed in health facilitiesshowed the following results:w Overall, 53% of the respondents were satisfied

with their jobs while 22% were neutral (neithersatisfied not dissatisfied).

w Male employees were more satisfied with theirjobs (59%) compared with the female employees(48%).

w Doctors/dentists are the least satisfied group ofhealth workers as compared with other carders.

w Satisfaction was lowest among the hospital staff(42%) compared with staff in health centres anddispensaries (82%)

The reasons given for the job satisfaction weregood salary (69%), job security (59%), staffdevelopment opportunities (35%), availability ofsupplies (34%), good management (21%) jobmatching with qualifications (21%).

Improving Responsiveness toClient Needs

MOH has developed and circulated theministerial service charter for healthservice delivery. It is a statement of intent,

defining the Ministry’s mandate, commitment,duties and obligations and the customer’s rights andobligations. It recognizes the community ascustomers with rights and as claimants withlegitimate demands on the health services. Thisdocument, launched in January 2007, could serveas a human rights instrument if properly used, andshould be monitored during the implementation ofthe NHSSP II. While it might be argued that ideallyservice standards should be developed in

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consultation with users, not issued from the centre,this service charter will form the basis for developinghealth facility level charters. The challengeremaining therefore is to develop health facilityspecific service charters as planned by the ministry.The health facility level charters need to provideinformation on the services available and specificstandards of care. These health facility servicecharters will need to be displayed publicly at thefacility in order to strengthen horizontal account-ability. The charters will need also to set outcomplaints and redress mechanisms in the eventthat the provider does not meet these standards Inaddition, it will be necessary to enhance the role ofcivil society in empowering communities to demandthe services to which they are entitled.

The ministry has also introduced clientsatisfaction tools at the facility level, starting withexit surveys, to monitor whether the providers havefulfilled their service obligations as per theexpectations of the clients. The results of the 2007Client Satisfaction Survey showed that 94% of clientswere satisfied with the health care services received.Most of the clients gave the following reasons forthe their satisfaction for the health care received;privacy/confidentiality (91%), cleanliness of facility(90%), good altitude towards patients (86%),improved supply of medication (72%) and shorterwaiting time (57%)

KEPH as a new mode of organizing servicedelivery may require the re-tooling of health workersand managers so that staff acquire new skills toenable them have the ability to do what is needrespond to the new challenges of deliveringintegrated health care services. Implementation ofthe planned strategies of a) reviewing and improvingbasic and in-service training of medical and para-medical staff, b) designing to enhance the clinicaland management skills of staff need to beaccelerated. In addition, activities aimed atencouraging the participation of men in reproductivehealth services and training of health workers inclient handling and patient centered accountabilityneed to be implemented.

Summary of Major Recommen-dations for Improving ServiceQuality and Responsiveness

Among other actions, there is need to establishmechanisms for performance reward as partof PAS roll-out plans. This should include

the mandate, authority, means and resourcesrequired to recognize and reward good performanceas well as address and improve on specific areas ofnon performance. In addition, MOH and the sectorshould:w Develop and implement HR development

strategy to support KEPH.w Develop the capacity of managers at all levels

to effectively implement and manage the PAS.w Strengthen systems and capacity for effective

integrated support supervision and qualityassurance programme at all levels.

w Accelerate the dissemination of updated clinicalstandards, protocols and guidelines for theKEPH including the ministerial service charter.

w Logistics chain management for essential andpublic health goods needs to be strengthened inGOK and PNFP facilities.

w Develop strategies for improving provider-clientrelationships and accountability includingdevelopment of health specific charters.

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Improving efficiency and effectiveness of thehealth sector is one of the core strategicobjectives of the Second National HealthStrategic Plan. The inefficiencies in various

support systems have been identified and variousstrategies planned to be introduced in the period ofthe NHSSP II. The objective has two sub-objectives:improving value for money by utilizing resourcesin the best possible way and reengineering theprocesses and procedures for better management,support and administration. The overall systemsfocus in the strategic plan is to ensure that inputs,money, human resources, commodities, etc., get tohealth service units in a timely way and are usedand managed well. The progress and the challengesof the last two years and the necessary actionsrecommended for improvement are presented below.

Improving Value for Money

Health resources (facilities, human resourcesand their associated operations andmaintenance [O&M] budget) are not

equitably distributed across the country. Rural andremote areas in particular are under resourced. TheNHSSP II therefore stipulates that these theresource allocation criteria be revised to incorpor-ate a poverty index into the allocation formula.

The resource allocation criteria currently in usewere developed in 2000. District resource allocationcriteria (Table 4.1) are based on existing infrastruc-ture and other population parameters, while hospitalcriteria are based on bed utilization and outpatientcases. Though the district RAC provides a weightof 30% of for poverty, it is recognized that it needsto be improved if the current resource allocationsare to favour underserved districts.

The wealth of evidence on the poverty profile inKenya has improved since 2000, with the publication

4. Progress with Objective 3: ImprovingEfficiency and Effectiveness

of the study on Geographic dimensions of povertyby KNBS. The criteria in use still do not explicitlycorrect to favour underserved areas. There istherefore a need to revise these allocation criteria.In doing so, lessons can be learned from the resourceallocation in the CDF and other innovativemechanisms used in the country and be adapted tothe condition in the health sector.

Table 4.1: District resource allocation criteria

Variables Weight (%)

Infrastructure 15Under five 25Poverty levels 30AIDS cases 5Female population 25Total 100

Improving FinancialManagement with Focus onFlow of Funds

Lessons learnt from the constraints of the pilotfinancial management systems under DARE/Sida, informed the NHSSP II objective of

setting a robust performance based accountingsystem, designed to enable timely disbursement offunds, timely production of financial returns andproduction of timely and accurate accounts of thesector. The major outputs planned in the PFMsystem were:

Efficiency and effectiveness involve emphasison value for money and the processes andprocedures for better management, support andadministration.

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w Strengthening the budgeting process;w Piloting a direct flow of funds and reviewing

the experiences for scaling up;w Build capacities of the system in terms of human

resources, software and skills;w Strategy to improve financial management

formulated;w Initiating pooled funding; andw Introducing performance based budgeting.

Achieving successful outcomes for NHHSP IIand the JPWF depends on the capacity of PFMsystem to deliver on aggregate fiscal discipline, thestrategic allocation of resources, and the efficientdelivery of services on a value for money basis. It isalso specifically dependent on the health sector’sinstitutional arrangements, like budgeting, procure-ment, expenditure control, reporting and accountingpolicies and practices. Finally, it depends on itsability to respond to and adopt corrective measuresto address internal and external audit findings.

Strengthening the budgeting process: Asindicated in the planning section below, the linkagebetween annual planning and budgeting process isbeing strengthened through the development of“shadow/functional budget”, that allows a linkagebetween the format of the national budget (asprovided in the medium-term expenditureframework – MTEF) and the planning format (bylevel of intervention as provided by NHSSP II andJPWF), specifically for use in the annual plans(AOPs). The functional budget is designed to reflectOn-Budget and Off-Budget contributions from thedevelopment partners and is broader than theMTEF requirements. This has allowed showing clearfinancing gaps by priority areas and levels ofintervention to be financed from earmarked and un-earmarked resources that are projected to come fromdevelopment partners. If strengthened andcompleted in time, it will help to develop atransparent mechanism for resource allocation inline with the priorities of NHSSP II and JPWF andresult in reversing the trends. Further work isrequired before it serves its intended purpose,however. This includes but is not limited to thedevelopment of a resource mapping format thatmeets requirements of both sector planning andgovernment budgeting processes; the willingness ofconstituent partners (government, developmentpartners and NGOs) to reflect their contribution(both financial and non financial) in time; theestablishment of a robust and committed workingteam to consolidate and consult all stakeholders onresource allocation in a transparent andparticipatory manner; and the setting andenforcement of a clear timetable for collecting andconsolidating available resources and providingimplementing units (both GOK and others) with areasonably sound and accurate resource envelopein time for planning (reference # 17).

Direct flow of funds was one of the mainstrategies planned in NHSSP II to improve valuefor money and improve utilization of budget allocated.The MOH is committed to the establishment ofHealth Facility Fund in order to streamline theefficiency in the flow of funds to the lower levelfacilities A process of initiating direct flow of fundsto health facilities using the education route wasinitiated in 2004. The process is still ongoing and isstill on preparatory phase.

A position paper on mechanisms of the flow offunds (Reference #20) has been developed and agreedby the sector stakeholders. The is also need to revisethe legal framework to make the health facility fundworking, as was communicated to the MOH in 2004.However, this prerequisite was not adequatelyaddressed and Treasury was not able to approvethe proposed scheme for its implementation.Preparations to use administrative procedures havebeen finalized and a draft legal notice has beenprepared waiting to be gazetted. Once the legalnotice is gazetted, rural health facilities will becomeaccounting units, therefore able to receive, manageand spend funds directly. Among the issues are:w HFF recipients are only government owned

facilities. Non-governmental service provider arenot yet planned to participate in the HFF.

w The financial resources transferred through theHFF are rather small and it is intended tofinance recurrent expenses for service deliverylike, e.g., transport, consumables and salariesfor support staff and common non-prescriptiondrugs for CHW outreach services.

w Too narrow definition of activities that can befinanced from HFF money.

w Resource allocation is not output based.

Until this direct flow of funds is functionalbudget releases to districts will continue to be rathererratic and comes from the MOH/HQ throughTreasury in the form of AIEs. DMOH are notinformed about their final budgets and have tooperate on the basis of their quarterly AIEs asplanning horizon. This will compromise therealization of the target plans in the annual plansas the emphasis will not be on planning andmanaging resources, but on making it possible torun the services and the hospitals. This has seriousconsequences with regards to budget predictabilityand implementation of planned activities.

The AGD, on request of the MOH, has alreadydeployed additional staff directly at the districthealth office level. This officers report directly tothe District Accountant. This is already analignment that reflects the MOH and MOFunderstanding of the challenges of the sector. Inaddition, the GFATM has funded one accountantin each district health office. With the operation ofHFF the need for more accountants to follow upand coordinate facility financial returns is apparent

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and needs to be budgeted in the HFF capacitybuilding budget.

The Kenya National Audit Office (KENAO), apart of the PFM reform programme, has recentlybeen reinforced with an Act of Parliament and hasbeen able to recruit and retain qualified staff since2004. Nonetheless, its capacity is still constrainedto about two-thirds of its staffing requirements. Inaddition, some of its units, such as the value formoney audit units, are recent and are still developingtheir methodologies and manuals and testing themin practice.

The KENAO established work plans cover therisks identified, yet these are constrained byresources. The SWAp calls for a special focus onthe health sector including the conduct of externalaudits. Such a demand cannot be met by theKENAO every year both in terms of scope and interms of breadth of sampling.

The identified activities not delivered are: de-concentration, development of PFM reforms to assistFBOs, NGOs, not-for-profits organizations, andintroduction of performance based budgeting, whichlooks unlikely to be implemented as MOF hasannounced its intention to introduce ProgrammeBudgeting in the next fiscal year. Generally the keyconcerns to consider include:w The need to re-examine its PFM system to find

out why its resource absorptive capacity isdeclining despite all the needs in the sector andto act and reverse the declining sector financialabsorptive capacity against a background ofresource allocation scenarios to the healthsector, that have not kept pace with the needfor growth of revenue generation largely becauseof its low absorptive capacity;

w The need to speed up PFM reforms in the sector,for which it will be necessary to enhanceconsultation and collaboration with MOF tobuild capacity in key areas.

w The need to address the ineffectiveness of HMISwhich is still unable to create linkage of thePFM to services delivery.

w The urgent need to substantially increase theminimal resource investments allocated tohealth infrastructure repairs and maintenanceso as to improve the level and quality servicedelivery.

Improving Planning, Manage-ment and Administration

In this category the review looked with particularinterest at the implementation of theCommunity Strategy, the planning system,

performance monitoring – including the healthinformation management system (HMIS) – humanresources, and commodity procurement.

Community Interface

One of the strategic shifts that NHSSP II introducedhas been the formalization of community servicesas part of the formal health service delivery system.All the policy documents since then (JPWF, AOP2, AOP 3) put the implementation of the CommunityStrategy as the sector priority deservingthe firstcall on resources. It specifically states the need toreorient the emphasis from facility-based to commu-nity-based promotive and preventive services.

Progress in the implementation process iscommendable (see details objective one). It still isat the initial stages and will face so many challengesduring the scaling up. The first challenge is to bringthe various types of community health workers andtheir mode of working according to the new mode ofimplementation. This requires a commitment of thecentral divisions of the MOH not to makecommunity service delivery a vertical part of thesystem as has been the case in the past and to ensurethat the various projects and programmes supportedby various development partners follow the nationalimplementation strategy. The second challenge isto ensure that community health workers aremotivated through implementing variousrecognition and motivation mechanisms that do notnecessarily have huge financial implications. Thecommunity health workers will be much moreeffective if they are supported by provision ofcommodities that are appropriate for their level.

There is ample evidence that provision ofcommunity kits to CHWs can contribute signi-ficantly to reversing the trends.14 The draftcommodity kit needs to be finalized and implementedas soon as possible. Fourth, so far the implementa-tion has been managed by DHMTs through publichealth facilities. There are various implementingagencies that have interest and experience tomeaningfully contribute to the scaling up process.There is thus need to work out ways the FBOs andNGOs could be involved in the implementation.Finally, as the implementation is being guided bythe principle of learning by doing, there will be willbe a lot of weaknesses in the strategies that requirecontinuous follow up and adaptation.

Planning System

NHSSP II and the JPWF recognize two distinctaspects of health planning in the sector. The firstrelates to “development planning”; the upstreamaspects of health planning covering the strategicinterventions for policy positioning, planning processand regulation of stakeholder engagement andcalendar. The second is the more operational aspectsof planning, particularly relating to operational

14 MDG document.

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district health planning. The emphasis and detailsin NHSSP II are on the strengthening of operational“district health planning” but with appropriatelybalanced attention to “development planning”.

Achievements in Health Sector Planning at theMidtermAt midterm a bottom-up planning process has beenfirmly instituted in the sector, with district healthplans (DHPs) now solidly rooted in the daily routineof the Kenyan health services. These plans are beingconsolidated, together with plans from other serviceunits in the sector, into annual operational plans.In general, peer support and stakeholder participa-tion in the planning process has increased,withplanning guidelines annually reviewed forimprovements. Training of DHMTs and stake-holders on development of DHPs was rolled out.

The Joint Annual planning has become moreparticipatory and comprehensive from AOP 1,through to AOP 3 where all sector constituentpartners have adequately contributed to, andeffectively participated in its development.Additionally, while not complete, much has beenattained to align the work of national verticalprogrammes with the NHSSP II planning processand the KEPH in AOP 2 beyond the status in AOP1.

Attempts have been made to harmonize thesector planning process with the Governmentbudgeting process, the MTEF. Articulation ofexpenditure limits for respective planning units wasinitiated in AOP 2, and strengthened in AOP 3development. In addition, a budget framework tolink the Government budgetary structure with theHealth Sector results oriented planning format wereinitiated in AOP 2 through a “shadow budget”. Thisshadow budget not only provides the linkagesbetween the planning and budgeting process, butalso captures off-budget resource flows.

The results framework15 from has beeninstituted in the planning process, and has nowmoved from a process base in AOP1 and AOP2, to a“core-function” base in AOP3. This development notonly clarifies the means of how the core-functionssupport the delivery of services, but in additionimproves the connection of how activities plannedfrom one year to the next collectively lead toachievement of the overall expected output.

To support follow up of planned activities, thesector has used the Government-wide results basedmanagement approach to initiate PerformanceContracts for top and mid level managers. Thesecontracts are based on derivation of results as

outlined in the respective AOP. These performancebased contracts have enabled adequate follow up,and achievement of joint sector results.

Tools and training material for roll-out of theCommunity Strategy are in place though not fullyimplemented. In support to follow up of the planningprocess, quarterly supervision efforts and interactionbetween MOH/HQ and PMOs have now also beeninitiated. A client-oriented implementation processwas initiated in the sector, with the intention ofincorporating the gender and human rightsconsiderations from AOP 3.

Finally, attempts have been made to consolidateplanning monitoring and health informationsystems, with establishment of a Sector Planningand Monitoring Department, SPMD. This isconstituted from the previous Health Sector ReformSecretariat, and the Health Management andInformation System division.

Challenges in the Health Sector Planning at theMidtermAdequate dissemination of the innovations in theplanning process in the sector has not beenadequately done. There are low overall managementskills and knowledge-base at province, district andat health facility levels. There is almost completelack of knowledge at the field level on how and whythe results framework has evolved from the level ofthe NHSSP through the JPWF, through AOP1 andAOP 2 then onto the core-function base in AOP3.This development process has manifested more aslack at district level, of a strategic planningframeworks linked to NHSSPII and JPWF ratherthan the commendable innovation noted above. Thismay be a reflection of the low level of impact of thecapacity building process.

The breadth of access to a stable and unifiedresults framework for the development of AOPs byprovinces, districts and health unit facilities, as wellas the inclusiveness in participation, of the variousstakeholders in the planning process andprogramme reviews still needs to be furtherstrengthened. While participation is now presentfrom all the three constituent partners in the sector,participation from within many of these constituentsis not yet comprehensive enough. Governmentparticipation is limited to the Ministry of Health,without adequate input from other Governmentstructures, and parastatals. Implementing partnerparticipation is at present limited to Faith Basedservice providers, and some civil society partnersoperating under the Health Network NGOs(HENNET) umbrella.

Linkages between the sector planning, andbudgeting processes is still not at an operationalstage. Information on allocations to differentplanning units in the sector gets to them too late toallow for appropriate, resource-guided planning. Theshadow budget, while a good initiative, is not

15 Results framework: The logic that explains how resultsare to be achieved, including causal relationships andunderlying assumptions. The results framework is theapplication of the logframe approach at a more strategiclevel, across an entire organization, for a countryprogramme, a programme component within a countryprogramme, or even a project.

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adequately supported to enable it function fully. Inparticular roles and responsibilities for planning andbudgeting need better rationalization.

The positive progress at central level in respectto improving capacity and structures for policydialogue are not being matched or reflected at thedistrict level. While the up-stream capacity fordevelopment planning has improved fast andtremendously, the capacity for district planning ismuch less spectacular and growing much moreslowly. The capacity building and training for theoperational district planning while commendable,is not yet comprehensive, as the capacities of thedistricts and provincial levels to support, andparticipate in the planning process is not adequatelyaddressed. These district and Provincial officials arethus not enabled to support the field level staff planappropriately. The lack of peer support, of humanresources, of logistics and financing required tocascade the AOP skills development capacity acrossan ever increasing number of districts is noted tobe a key challenge.

The uncertainty, and frequent modification, ofindicators, together with the continuing delay inroll-out of improvement in the monitoringframework, combine with the rapid evolution of theresults framework to cause what appears likefrustration at the frontline planning levels in theplanning efforts of district staff at the primaryservices output end of the system.

The year-on-year lessons learnt fromimplementation of the AOPs are not being effectivelyshared and systematically mainstreamed down todistrict level resulting into a rather mechanical andconceptually narrow process, the rationale of which,is much less understood downstream. This may inpart be due to the slow progress with roll out ofmedium-term policy frameworks and plans oftechnical programmes, required to support districtsout of this dilemma. The AOP 3 has initiated actionwhich ought to mitigate this effect.

The separation between regulation andimplementation operations of service delivery isurgently needed to improve the regulation, planningand efficiency of operations of the system. And thereappears to be no initiative in place to develop asystematic operations research agenda for probingsystems constraints. In addition, while gender andhuman rights considerations were incorporated intoAOP 3, the guidelines and training materials of thehealth sector planning processes are not yetexplicitly addressing these issues. There is currentlyno designated official responsible for human rights,equity and gender mainstreaming in the Ministryof Health. Yet, it is important that there is if anysustainable progress is to be expected.

Although the AOP process is gaininginstitutional stability and being mainstreamed intothe planning cycle at all its stages, the same is nottrue of the JRM. The latter still appears very rushed

and important thing may inadvertently fall throughcracks. Again in this respect the generalrecommendation of the first JRM still holds. TheJRM is not yet a bottom-up process as recommended.It is not based upon continuous observations madethrough-out the planning cycle. The rapid singlepoint assessment approach over one week or two,with or without external consultants, does little orno justice at all, to the required assessment of theyear-long planned and carefully conductedoperations of the AOP. Being de-linked from thequarterly performance monitoring events rendersthe JRM process ineffective in contributing to thestrengthening of reporting compliance of thequarterly supervision thus weakening theinformation base for the JRM stakeholders’ forum.

Looking at the institutional capacity formanagement of the planning process, the capacityat the SPMD is not well matched with the workloadto build and operate a suitable planning frameworkfor the country. Key capacities, particularly in theareas of budgeting, exist the Planning Unit.Additional capacities for monitoring particularly foradministrative functions exist in a different unit,the Ministerial Monitoring Unit (MMU). These needto be linked better with the SPMD for the sectorplanning function be more effectively coordinated,and strengthen the weak linkages between theplanning, budgeting, and regular monitoringprocesses.

Performance Monitoring

The objective of the M&E support system articulatedin NHSSP II is to assist health managers to makeinformed decisions and contribute to better qualityplanning and management. This objective isplanned to be achieved by harmonizing HMIS toolsto make them practical, decision oriented andperformance oriented; investing in human capacity;(iii) triangulating facility- and population-basedinformation; and stimulating operational research.The results anticipated by NHSSP at midterm werethat the planning, monitoring and evaluation (PME)system would be established, functional and in useby managers for decision making for better qualityplanning and management of services. These resultswere to be achieved by: (a) revising data collectiontools so as to restore functionality; (b) investing inhuman capacity for monitoring and evaluation; (c)conducting analysis across relevant healthinformation databases to monitor health status andtrack programme performance; and (d) buildingoperations research capacity to support NHSSPimplementation and collaboration with researchinstitutions for health development.

The focus of the effort has been towardspreparation for and revision of monitoring indicatorsfor the sector. This is three pronged, focusing on

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1. Establishing a mechanism for performancemonitoring for the sector

2. Strengthening coordination of routine healthinformation system, and

3. Scaling up the Integrated Disease Surveillanceand Response mechanisms.

Their linkages and expected roll out arehighlighted in the sector’s performance monitoringframework.

Activities to strengthen the performancemonitoring mechanisms have formed a strong focusof activities during the first half of NHSSP II.Achievements in these are highlighted in the sectionon partnerships, but relate to adoption, and use forAOP planning and monitoring of a set ofperformance indicators. Reporting has consistentlyimproved, with the reporting response greatlyimproved from 17 districts that did not report at allduring AOP 1, to all districts reporting in AOP 2.

Regarding coordination of routine healthinformation system, progress has been made inbringing together various users to agree a consensusset of indicators and tools. An inventory of tools hasbeen prepared and software development has beeninitiated along with assessment for computerhardware acquisition to automate the HMIS. Aprocess of harmonization of indicators was carriedout over a year because of the need to reachagreement with PHMTs, DHMTs, DPs, NGOs,FBOs, and programmes on indicator list andvariables associated with them. This multitude oftools have now been consolidated into 12 differentregisters and 6 summary reporting forms for alllevels. The harmonized and agreed consensus set oftools has been costed and a draft sector monitoringand evaluation (M&E) framework and plan preparedfor tabling by the Ministerial Monitoring Unit(MMU) before the sector decision makers to approve.In the meantime, preliminary self motivated work,supported by some of the partners has given thebasis and foundation for consultation and agreementon a national data collection package. This nationallyagreed data collection package for routine healthinformation has been rolled out to cover a total of23 districts in 3 provinces and over 600 healthworkers trained on data collection tools and theiruse. During AOP 2, out of the total 5,170 healthfacilities, 3,071 have submitted their reports, givinga completion rate of 63%.

The disease surveillance and response functionhas been rolled out in the country during the firsthalf of the country. Capacity building process andpackage was designed, and out of the existing 78districts in the first half of the NHSSP II, 61 hadteams oriented by the end of 2007. Capacity buildingin the remaining districts, plus the newly createddistricts is planned. In addition to the capacitybuilding, the reporting mechanism and systemfunctions reasonably well with clear outputs and

with an outbreak notification system and a bulletin.The function of disease surveillance, with previouslywas coordinated in the respective verticalprogrammes, has now been brought together in theDivision of Communicable Disease Control.

Information ManagementA coordinated and structured utilization ofinformation has been initiated. Automation ofinformation was been proposed for AOP 3, withinitiation of spreadsheet applications and FTPmechanisms to ease and manage information better.Quarterly monitoring visits have been initiatedbetween national and provincial levels, whereperformance monitoring information is discussed.Monthly reporting on routine health information isalso being encouraged using the agreed datacollection tools. A sector “Facts and Figures at aGlance” booklet was developed in 2006, and a draftannual statistical report for the last two years isunder preparation. In terms of routine operations,the component for services data management(HMIS) is only nominally functioning largely to storedata. It has qualified staff. The HMIS has also main-tained contact with vital registration departmentand the central office of statistics, largely facilitatedby the Health Metrics Network process. Finally,the disease surveillance information is collated usinga well functioning outbreak notification system, anda bulletin. Coordination of information managementfunction has also improved at the national level,with the performance monitoring and healthinformation systems now managed in onedepartment.

A lot of policy related operational research hasbeen completed. These researches include theAnnual MPERs, human resource mapping, publicexpenditure tracking, impact of user fees (10/20)policy, costing studies, FBO facility assessments andvarious other service-related surveys. These reportshave come up with very useful policy findings andrecommendations.

Challenges in Monitoring at the MidtermThis very slow and modest progress in rolling outthe strengthening activity for the monitoring andevaluation component of the NHSSP. This has beenthe most constraining factor to implementation ofmany of the NHSSP components. Efforts tostrengthen the M&E activities are not adequatelyguided by the strategy for strengthening M&E, asit has not yet received official endorsement of thesector. All other elements due at midterm (capacityenhancement of human resources, analytic capacity,roll out of new data collection tools and capacity foroperations research), are only just initiated and farfrom significant progress towards midterm targets.

While the performance monitoring mechanismhas been successfully initiated, there is still a highlevel of misunderstanding, and therefore interpre-

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tation of its use, vis-à-vis the other monitoringmechanisms. There is still a strong push foradditional indicators, particularly from vertical pro-grammes, into this performance monitoring system.This has led to an annual modification of indicatorsused for performance monitoring, makingcomparisons across the years more difficult. Atpresent, there are 71 health performance indicators,of which 43 are expected to come from the routinesystem with the rest from population-based surveys.

The roll out and use of the coordinated tools forHMIS is still very weak, and vertical programmereporting mechanisms are still in place. It is estimat-ed that a nurse at the dispensary maintains about55 registers and spends at least three person-dayseach month to fill reporting formats. The margin oferror between the information in the registers andreports submitted can be as high as 80% and thereare still gross delays in submitting reports.16 Mostindicators were defined in NHSSP II, but the needfor refining them arose as there were importantprogrammatic indicators that were missing.

The roll out of the IDSR was facilitated bysupport through resources for emergency activities.Resources from Government, or sector partners arenot adequately channelled to support strengtheningof IDSR in the country, though it remains a keyarea of support.

The poor logistic and financing support to theHMIS function in the sector is partly responsiblefor the non-performance in this results area but moreso the poor support in terms of financing andtechnical oversight of the field level. The limiteddirect support, strongly complemented by supportfrom the vertical programmes, is patchy in contentand fragmented in coverage. This support fromvertical programmes has tended to be tagged to theprogramme’s specific needs, deviating attentionfrom the comprehensive sectoral approach tomanagement of the health information functions.Untargeted financial support has been strongest forthe IDSR and performance monitoring aspects, whilethe HMIS coordination has largely been driven byprogramme resources.

Capacity to support information managementby HMIS tends to be sequestrated in vertical pro-grammes and not available for sector-wide informa-tion management development. The investment inhuman resources involved in the informationcollation is not systematically carried out. Long-term technical support for health informationmanagement is not strategically sourced ormanaged and so no is not able to provide effectiveupstream technical assistance. The availabledownstream technical assistance is more foradministrative purposes and of little technical value.

Health system input databases (e.g., nationalinventories of the health workforce, national healthaccounts, etc.) are not collated but left with source

departments without much regular triangulationof data for information generation to support policy.Performance targets are therefore not linked toresource availability in the planning process.

Supervision is irregular and rare, withfragmented responsibility for monitoring. Thequality of information is quite low as a result andthere are many obvious errors in results.

The impressive number of surveys withrelevance to the sector is not taken full advantageof either to build human capacity or content of healthsector data sets. Involvement with the censusprocess and Demographic and Health Surveys isnot strategically coordinated.

The implementation of the automation of healthinformation management will need to beaccelerated, and done comprehensively toappropriately manage the transition period. Untilsuch integrated automation is operational, theparallel information systems that are currentlyfunctional in the MOH are likely to continue.

Finally, looking at the extent of research carriedout, the extent to which these recommendations areimplemented and the policy findings used fordecision making is not verifiable. It is thereforenecessary to put in place a mechanism providingthat only relevant and informative surveys arecarried out and that study findings be usedeffectively to inform decision making.

Human Resources

The strategic plan in its human resource sectionaims to optimize the use of available humanresources by instituting sound managementprinciples at the central level and decentralizingcertain functions where appropriate. This objectivewas planned to be achieved by (a) creating anenabling working environment (norms, values,guidelines and tools); (b) aligning tasks andfunctions of existing work force; (c) introducingresult and performance oriented contracts alongwith supportive capacity building measures; and(d) strengthening leadership, management andsupervision accountability to enhance healthworkers’ motivation and performance.

To address these objectives a national humanresource strategic plan (2006–2010) was developedas part of JPWF. The main outputs of the HRHstrategic plan are:w Improving the planning, distribution and

management of the workforce.w Redistributing the workforce to ensure more

equitable service delivery.w Undertaking initiatives to improve institutional

and health worker performance.w Ensuring effective supervision systems.w Improving the quality of basic and pre-service

training.16 JDM report, page 36.

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w Making appropriate use of in-service trainingand continuous professional development.

w Restructuring and strengthening humanresource planning and management.

The strategic plan clearly stated that the humanresource requirement needs to be worked out. Aspart of the JPWF, based on the serviced defined tobe provided under KEPH, the sector developed sectornorms and standards that clearly defined theservices to be provided, the human resourcesrequired by cadre, and the infrastructurerequirements for each level of service. These normsand standards are the standards that the healthsector is aspiring to implement in the coming years.While the strategy is approved for implementation,the extent to which they are being used fordeployment and redeployment of human resourcescannot be ascertained. It also required further workto make it more binding for enforcement for thepurpose of budgeting and establishment of any newfacility by any actor in the country.

The JPWF planned to recruit 2,615 additionalhealth workers for 2006/07 and 2007/08 and 3649staff were employed, over 40%t more than what wasplanned (See section on improving access).

In addition to employing additional staff,putting in place an efficient and robust HR systemsand has been one of the major strategies in NHSSPII. The current government systems for recruitmentand deployment are slow, and lack of sufficientlyrobust controls. The current inefficiencies in thegovernment recruitment and deploymentprocedures result in substantial cost and effort(spread over a number of actors) for a limitednumber of posts and can take several months torecruit and deploy staff. For example, of the 571positions advertised by the Public ServiceCommission (PSC) in May 2006, only 230 staff hadbeen appointed and deployed in February 2007. Incontrast, the emergency recruitment processrecruited and deployed 1,600 health workers in threemonths. This clearly shows the need to reengineerand streamline the recruitment process in the civilservice in general and/or work out strategies to fasttrack the recruitment process for HRH.

There were also efforts to develop a databasefor HRH. The Integrated Personnel and PayDatabase (IPPD), data from the Mapping Study,and the nursing database developed as part of theKenya Nursing Workforce Project have improvedthe HR information available to plan, manage anddevelop the health workforce.

Although NHSSP II has outputs regardinghuman resource development, there has not beensubstantive effort in implementing the aspirationof the plan. The HRD plan is not yet in place,training needs assessment (TNA) have not beencarried out and consequently training programmeshave not been designed in accordance to the findings

of the TNA. There is a need for improved informa-tion on pre-service training (PST), in-servicetraining (IST) and continuing professionaldevelopment (CPD) in order to assess the capacityand quality of the HRD system to meet current andfuture demands. Information on numbers and typesof programmes, number and capacity of facilities,numbers and types of teaching staff, current andprojected intakes and outputs is required tostrengthen the planning and coordination of humanresource development systems. This isacknowledged in the JPWF, and the HRH compo-nent of AOP 2 sets out several activities to addressthis issue.

In order to improve the performance of the workforce, the government wide, National PerformanceManagement Framework (NPMF) was introducedand would institutionalize the results-basedmanagement approach in the health sector asplanned in NHSSP II. in addition, the Governmenthas approved for implementation, a newPerformance Appraisal System (PAS) for the PublicService. These developments will support thestrengthening of performance management systemsat facility and individual. Support will be requiredto effectively introduce and institutionalize the PASat all levels.

These improvements in pay are attracting morehealth workers into the system, but it is unclearwhether the improvements are sufficient to retainthem and reduce attrition. The available informationon external migration indicates that there are stillsignificant numbers of health workers leavingKenya to work overseas. The improved terms andconditions for government health workers arecausing greater disparities in employmentconditions for public and non-public health workers.The large number of applications for MOH jobs fromhealth workers employed by the FBOs suggests thatit there needs to be harmonization of scheme ofservice between the public actor and other actors.

The Mapping Study identified that there was aserious mal-distribution of staff (particularlybetween urban and rural areas), and NHSSP IIclearly called for “policy recommendations of thehuman resource mapping study to be implementedand the redeployment of staff nurses and doctors tobe addressed”. little appears to have been achievedin this area, however. Redeployment of staff needsto be effected by a mixture of more appropriateincentives and - in the public sector - strengthenedsystems for deploying staff. In particular, ways ofmaking the “hard-to-fill” posts more attractive needto be developed, and targeted not just by cadre, butalso by age group, gender and other characteristicsidentified in studies on “push” and “pull” factors.

The HRD Unit and the Office of ContinuingProfessional Development (OCPD) within the MOHcould have a greater role in supporting the sector toadopt a more strategic approach to HRD. They could

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support the development of a HRD plan, thedevelopment of training information systems, theassessment of training needs, curricula developmentand the monitoring of capacity developmentinitiatives.

The multiplicity of stakeholders involved inHRH requires robust coordinating structures andmechanisms to ensure that HRH are coordinatedacross the sector. The fragmentation and weakcoordination of the HR function within MOHheadquarters is contributing to weak and inefficientHR practices and reduces the sector’s ability tomaintain a strategic HR perspective. Improvedcollaboration and partnership with other non-government service providers is required. There isalso a need to strengthen information flows andcommunication between MOH and DPM / PSC.Appropriate mechanism of coordination needs to beenvisaged and implemented to enhance policydialogue across the sector at both strategic andtechnical levels and to improve strategic oversightand coordination of HRH.

The implementation of the above strategies isquite weak for many reasons. Most of the reformsin articulated above can only performed in line withfunctioning civil service laws and regulations.Ministry of health, as being part of the civil service,needs to work within the overall governmentreforms. A meaningful change in the managementof human resources for health can only achieved ifthere was strong engagement with the DPM. Theleadership in the human resource management hasnot been able to steer the implementation of thestrategies. The progresses recorded below have beenachieved not because of attempts to systematicallyimplement these reforms but because of fragmentedefforts exerted by stakeholders.

Procurement and CommoditySupply Management

The NHSSP II stated that the EMMS and medicalsupplies procurement, their distribution andrational use comprise a complex system ofinstitutional, legal and policy related matters thattogether frustrate attempts to respond to reform.The strategies planned in the NHSSP 2 in the areaof procurementw Institutional appreciate procedures for

decentralized (demand driven commodityprocurement) i.e., arrangement for regulation,procurement and distribution; and implementdemand driven procurement system in 50% ofdistricts.

w Update annually resource constrained mediumterm procurement plan (MTTP) to procurementof commodities.

w Ensure improvement in the availability ofessential medicines and medical supplies in the

sector through revision of national drug policyand Essential Drug List, strengthening EMMSsupply management improve rational use ofEMMS.

In the last two years the sector has spend moretime in analysing the weaknesses of theprocurement system and agreement on the wayforward. The Government, MOH and developmentpartners have carried out various procurementassessments and studies of the public procurementand supply chain systems and practices. Theassessments indicate that there are significantrisks, as the systems are inefficient and thereforefail to achieve value for money as well as associatedwith wastage and corrupt practices (see theprocurement system improvement plan and the JSPReports) for detailed weaknesses of the system.

The revised legal framework has (publicprocurement and disposal act, 2005) provided healthfacilities with a procurement entity status. Noprocurement is undertaken without fund avail-ability. An annual procurement planning processhas been introduced to guide the overall sectoralprocurement resource allocation process, but itrequires further refinement in terms of its link tothe budget, broader participation and analysis.Procurement Review Boards and an oversightauthority have been put in place. Senior procure-ment staff have been posted to the MOHProcurement Unit, capacity building is addressedby MOF. In short, these improvements are startingto show results. There is already a well thought outprocurement and supply chain managementimprovement plan that is part of the JPWF; thechallenge is to implement it

The “Position Paper on Procurement”,December 2006 outlines the key policy decisions andactions that need to be take to institute a demanddriven procurement systems with its appropriatechecks and balances through a ‘drawing rights’ offacilities. While there is a lot of concern on theefficiency and effectiveness of the procurementprocess, there is very little investment from partners(with the exception of the few) in strengthening thenecessary checks and balances in the system.

KEMSA has been provided with the responsi-bility of procuring bulk purchases since July 2006.The distribution EMMS from KEMSA has improvedand every facility is receiving consignments oncein a quarter. Most hospitals are now receivingEMMS on demand driven basis from KEMSA. Thesystem of delivering vaccines to districts and tofacilities appears to work well. There are more drugsnow in the health facilities than in the past. Anevaluation of the Kenya Medical Supplies Agency(KEMSA), September, 2006, concluded that KEMSAhas developed and implemented transparentprotocols but recommends that it needs to controlits own finances. The evaluation report concludes

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(a) that development partners are reluctant to providesupport until the Government and the MOH havedemonstrated that they are fully behind KEMSA,allowing it to assume authority and responsibilityfor its full mandate, and (b) that administrativeaction is rarely taken on non-compliant officials.

Despite these developments, implementationdelays continue to undermine the effectiveness ofthe procurement system in MOH and negativelyaffects service delivery. Many of the NHSSP IIcommitments have not been delivered, mainlybecause of capacity constraints. In addition, MOHand development partners have, during the last twoto three years, carried out procurement assessmentsand studies on the public procurement in theministry and identified current problems as: 1) lackof capacity in sector ministries including MOH, 2)lack of health sector specific regulations, 3) uncleardemarcation of responsibilities between MOH andorganizations under e.g. KEMSA, and, betweenvarious levels of facilities in the Ministry, togetherwith inefficiencies and ineffectiveness of the system.These problems are further compounded by the lackof concrete links between the HMIS andProcurement Management Information System(PMIS). Such a linkage would make it easy to assessand validate procurement of goods and servicesagainst service delivery. Of particular concern isthe delay in updating the EDL and updating of theKNPP Policy, both of which have implications onquality of service delivery. Revision of KenyaEssential Drug List has not been done as yet,though a draft has been made and is awaitingestablishment of the National Medicines andTherapeutics Committee (NMTC) by MOH.Generally, many commitments appear to have beenmade without due consideration of the capacity ofMOH to deliver on them, but the currentmanagement (the PS), demonstrates a high degreeof appreciation of what needs to be done. Despitethis commitment, capacity to implement the desiredreforms remains a problem. Therefore there isurgent need to rebuild credibility, and moreimportantly, to ensure the public gets quality goodsand services, on timely basis and value for money.

There is commitment and interest both on thepart of the overall government and MOH to reformprocurement and supply chain management,starting with making key policy decisions in thisarea. While the plans are clear on what needs to bedone, all sector partners need to demonstratecommitment by taking practical actions tostrengthen the system rather doing on business asusual approach. DPs need to support these effortsto finance the required system strengthening effortsrather continue lamenting the weaknesses of thesystem. Staff interviewed at all facilities during theJRM process agreed that door-to-door delivery wasa great improvement over the previous systemwhereby they collected supplies from higher level

facilities. In terms of regularity of delivery, commo-dity accounting, ease of use, and supply availabilitythe new supply transport system is a solidachievement. Among key issues and constraintsidentified were the poor communication andcoordination between third party (developmentpartner funded) procurement agencies and KEMSA,which is tasked with receiving, storing anddistributing goods procured by other agencies.KEMSA does not receive timely notification ofdeliveries and future distribution schedules thatwould allow it to manage its core functionsefficiently. Moreover, KEMSA does not recover itsoperational costs. Public sector clients (HFs) do notpay any handling charges for procurement, supplyor distribution. There was an agreement (March2007) for development partners to pay a 5% handlingfee to KEMSA for warehouse and distribution, butto date this has not been implemented.

Institutional arrangements for regulation,procurement and distribution in the pharmaceuticalsector, focusing on MOH involvement in policy,planning, finance and monitoring, reviewed, withspecial attention given to transparency andaccountability in the area of procurement andfinancial reporting.

Over the course of a 15-month period, the oldKenya National Drug Policy 1994 was subjected tointensive review by a Working Group establishedspecifically for that purpose involving all the keystakeholders (including special input from WHOGeneva) which was supported by a special TaskForce. A new, comprehensive Kenya NationalPharmaceutical Policy (KNPP) 2007 was draftedto replace the old policy document and wassubmitted for further review at a NationalConsensus Meeting in August 2007. Agreedresolutions and recommendations from that meetingare being incorporated into the draft and a fewoutstanding issues are being addressed in order tofinalize the work and prepare the document forsubmission through MOH Senior Management tothe Cabinet for formal approval and adoption. Thefive year strategic plan for the pharmaceutical sectorwill be developed once the KNPP has been officiallyadopted.

Annual procurement planning has now becomewell established and takes place towards the end ofthe first quarter of each year at a special retreatinvolving all the concerned parties. Considerableinputs have been provided by the Division ofPharmacy in the form of assessment of kit contentand performance and quantification of annualrequirements for both kits and bulk (loose) items.The result of this has been greatly improvedprocurement planning and much improvedavailability of EMMS at all levels with subsequentsubstantial increases in out-patient attendance atmany health facilities (particularly in districts nowunder the demand-based (“pull”) supply system).

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Challenges still to be tackled include the long-delayed transfer of procurement of essential medicalsupplies (‘non-pharmaceuticals) from MOH toKEMSA and further streamlining andstrengthening of the quantification and procurementprocess at all levels.

Following a systematic process of baselineassessment, sensitization, training, and preparationand dissemination of relevant documentation (e.g.,order forms, stock cards, guidelines) the ‘pull’system is now well established in two provinces(Coast and North Eastern) serving nearly 300 ruralhealth facilities, which have to date received sevencycles of quarterly supplies. Order fill rates of up to90% have been achieved and are averaging over 75%.Guidelines for ordering by the facilities are incor-porated into the training materials and consolidatednational guidelines on all aspects of EMMSmanagement at facility level are at an advancedstate of preparation. Nairobi Province (60 healthfacilities) was also inducted into the system inAugust 2007.

Strengthening drug supply management(including procurement, reception, warehousing,stock control, inspection and monitoring) receivedattention during the intensive training involved inpreparation for introduction of the pull system.Evidence obtained in the course of regular pullsystem performance assessment field visits showsthat there have been considerable improvements inseveral key areas of EMMS management at facilitylevel (e.g., better storage conditions andarrangements, improved stock records and quanti-fication, prompt order preparation and submission)but that serious challenges still remain to beaddressed. These include: the need for regularretraining to compensate for the adverse effects ofhigh staff turnover, the need to establish andinstitutionalize a pharmaceutical supportivesupervision system within the DHMTs to providecontinuous support to RHF staff for maintainingeffective operation of the pull system.

The revision and adoption of Kenya EssentialDrug List (EDL) has not been implemented as it isstill awaiting the long-delayed establishment of theMOH National Medicines and TherapeuticsCommittee (NMTC). It is expected that thiscommittee will be established and becomeoperational before the end of 2007. In the meantimethe list of EMMS to be supplied to RHFs and (sub-)district hospitals has been subject to continuousreview and annual updating as part of the annualprocurement process.

Draft guidelines for rational drug use at primarycare level have been developed for three maintherapeutic areas (IMCI, malaria and STIs) andused in the training of RHF staff as part of the pullsystem introduction. In a separate process, a draft487 page update of the Clinical Guidelines 2002 hasbeen prepared by an MOH working group and is

currently being distributed for review and comment.A draft Kenya National Formulary for PrimaryCare Level which covers all EMMS used at KEPHlevels 2 and 3 has been prepared and will besubmitted to the NMTC once this is established forformal review and adoption. The area of medicinesutilization remains a major challenge and there iscontinuing evidence of high levels of inappropriateuse and consequent waste and therapeuticcompromise. This will receive increasing attentiononce the required documentation is completed andready for introduction and dissemination.

This capacity drug supply management hasbeen significantly increased at RHF level in the pullsystem districts as a result of the intensive trainingprogramme involved in introduction of the system.RHFs in eight other districts in Central and EasternProvinces have also been trained in this area in ajoint/KEMSA exercise supported by one of thedevelopment partners. Drug management informa-tion tools including Standard order Forms and StockControl Cards have been developed and distributedthroughout the pull system districts and a newPrescription form is in print for testing in thesedistricts prior to national introduction.

Guidelines on the establishment, role andeffective functioning of institutional Medicines andTherapeutic Committees (MTCs) were prepared bythe Division of Pharmacy and distributed to allhospitals in March 2007. Requested responsesregarding to the status of these committees andrelated issues in the form of a structuredquestionnaire are being compiled analysed with aview to planning further support for theirestablishment and functioning. A special MTCworkshop is planned for approximately 10-15 of thebusiest hospitals later in 2007.

Investment and Maintenance

The NHSSP II has planned interventions oninvestment and maintenance in the health sector.The progress in investment for increasing accessfor care is well described in earlier sections and willnot be repeated here, but efforts to strengthenmaintenance systems have been planned, and theseare reported below.

The main outputs planned are related toinfrastructure and equipment as well as transport.According to NHSSP II, they are:w Assessment of the conditions of infrastructure,

equipment and transport including ambulances.w Policies on maintenance, transport are developed

and implemented.w Capacity building in the three area in terms of

human resources.w Establishment of maintenance units at district

level and community transport system.

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Efforts were made to strengthen district basedtransport system in Coast and provinces. Thetransport system assessment found that there areno standard transport information systems in place,no reliable transport data, ad hoc systems of vehiclescheduling, no systematic vehicle maintenanceschedules and procedures, no defined role for trans-port management responsibility, age of most of thefleet exceeded economic lifespan, and no accountablebudgetary statements relating to transport relatedexpenditure are available. The interventionsplanned to strengthen the system include:w Put in place an information based transport

management system, key performanceindicators, and operational guidelines;

w Train district level transport officers to operatesystems and apply guidelines;

w Provide a curriculum for training motorcycleriders and vehicle drivers in the safe drivingand riding techniques, and planned preventivemaintenance and procedures, and train riderand driver trainers for each district;

w Link operational costs and vehicle replacementcosts to the management information systemand district and provincial budgetingprocedures; and

w Provide an “ideal fleet” model, disposal andpurchase plan.

There are achievements recorded in streng-thening the system in the Coast province. There isan information-based transport managementsystem in place at provincial level and in each ofthe districts; skills and software are available formanual and computerized generation of keyperformance indicators. There is a DistrictTransport Officer in post in each district – but only3 of the 22 Transport Officers who attended hadcompleted all three trainings, meaning thatknowledge and skills of Transport Officers arevariable. Vehicle scheduling procedures are now inplace in each district. A number of riders and drivershave been trained to a basic level. There is nocurriculum in place for on-going training becauseno riders and drivers with sufficient basic skills tobe taken into a training of trainers programme.There is a system in place to evaluate vehiclemaintenance work undertaken by private sectorservice providers. A partnership agreement hasbeen drawn up between provincial MOH andMombasa Polytechnic to train senior drivers fromeach district in Planned Preventive MaintenanceTechniques. The system is in place to linkoperational and replacement costs to district andprovincial budgeting procedures, although the lackof central level directives and demands forspecification do not allow operational and capitaltransport costs to be meaningfully consolidated.17

This experiences needs to be widely shared and theircost effectiveness reviewed and scaled up withnecessary adjustments if any.

The effort at midterm may not be on track toaffect the key issues being addressed in terms ofhalting the poor maintenance and non repair ofhealth infrastructure due to poor planning and followup of maintenance of the procured infrastructure,rationalizing basic technical and administrativeequipment to support service delivery, including forcommunication, ICT and transport, to comply withdefined standards and guidelines for equipment soas to match them to expected functions. Thiswarrants a sound evaluation by the central level todecide on a way forward on the transport, equipmentand health infrastructure development andmanagement policy as well as development of a morerational human resource management policy.

Communication and ICT

NHSSP II aimed at improving the communicationamong various actors through development of anational communication plan or strategy,production of newsletters, the use of radio trans-mitters for emergency evacuation in remotefacilities, establishment of functional informationcommunication technology (ICT) networks in theheadquarters and to progressively expand toprovinces and districts.

The government wide ICT policy is beingimplemented in the Ministry of health and the policyis clear on what the health sector needs to doregarding ICT which eliminates the need to comeout with a specific health ICT strategy or policy.What is required is to know what it takes (in termsof resources and time) to implement the strategy inthe health sector. A TOR is drafted and animplementation plan is expected to be completed bythe end of AOP 3. There is a regular newsletterbeing printed and distributed by the MOH. It maybe necessary to improve its quality and expand itsdistribution list. An ICT network is functioning inAfya House and is being expanded to wide areanetwork to include other offices and provinces.

Recommendations forImproving Efficiency andEffectiveness

To meet this NHSSP II objective action isrecommended in all areas of efficiency andeffectiveness: improving value for money,

public financial management, efforts to strengthendevelopment planning , monitoring, district healthplanning, commodity supply management, and

17 “The Development of a District-Based Health TransportManagement System, Coast and North Eastern Provinces,Kenya”, January 2007.

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investment and maintenance. These are itemizedbelow.

Improving value for moneyw Undertake further reallocations of public

funding towards pro-poor programmesespecially rural health services in light ofcurrent poverty levels that justify more waversof facility fees to alleviate financial constraintsto health services access by the poor.

Improving public financial managementw Accelerate the implementation of PFM

improvement plan.w To reverse the declining capacity to absorb

finance resources, conduct an urgent evaluationof its PFM management.

w Implement the Health Sector Service Fund(HSSF).

w For MOH and development partners, enhancecollaboration to reduce parallel and fragmentedPFM systems in the health sector through theimplementation of the JFA.

w Fast track capacity building in financialmanagement and, for development partners,step in and help build capacity, especially inPFM for the implementation of HSSF.

w For MOH, in order to promote financialpredictability, develop criteria for cost sharingwaivers and provide a clear policy strategy forthe health sector so as to avoid disruptivedecision making.

w Strengthen data capture to ensure expenditureis consistent with the service delivery.

w Expedite increasing of benefits by NHIF totransfer efficiency gains to the contributors.

Improving the effort to strengthen district healthplanningw The priority is to scale-up the roll out of the

training for AOP preparation at all levels withincreased peer support to districts andprovinces, timely circulation of planningframeworks, expenditure ceilings, formats, and/or guidelines and tools beginning withpreparations for AOP 4.

w In light of the core-functions based resultsframework used in AOP 3, the MOH technicaldepartments should review their respectivestrategic approaches in line with the presentpolicy and strategic directions. This should helpin identifying gaps in delivery of their respectivepolicy and strategic frameworks required to rollout their technical interventions in line withthe implementation of the KEPH.

w Urgently prepare districts and provinces withmanagement and planning skills training soas to take over the in-service AOP skills-sharpening training for more rapid, effective and

wider coverage of the undertaking before theend of NHSSP II.

w Enhance the administrative and logisticssupport available to provinces, districts andhealth units to conduct more inclusive annualplanning with more meaningfully participationof civil society, FBO/NGOs and other partnersstarting in AOP4 for the AOP5 process.

w Consider and prepare for the introduction ofmedium term planning frameworks for districtsand provinces to set the direction for sustainabledecentralized operations, especially for themaintenance of capital investments inbuildings, plant and equipment.

Improving efforts to strengthen development planningw Enhance capacity at the central level in

technical planning to ensure implementationof the strategic approaches identified ismaintained.

w Strengthen policy dialogue structures at sub-national level requires with the establishmentof appropriate structures to improveengagement of civil society and partners in theplanning and sector review processes.

w Ensure that gender and rights sensitivity areincluded in training materials and planningformats and consider the establishment of a focalarea at the national level to coordinate thiswork.

w Rationalize and harmonize the planningfunction, and planning cycles with budgetingcycles as soon as is practical

w Restructure the MOH to make a succinctlyclear distinction between monitoring ofadministrative support to technicalimplementation (by the MMU) and the separate,well differentiated functions of technicalmonitoring and evaluation of sector productivity(by the SPMD through the division of healthinformation).

w In the same vein, appropriately delineate andappropriately disseminate the difference betweenthe functions of linkage of budget managementprocesses of the Ministry of Health (and onbudget donors) with the overall Government (bythe planning unit), and the separate technicalresults based and bottom up comprehensivesector planning and budget process based onplanning and monitoring sector productivity (bythe SPMD).

w Redesign and reform the JRM process to becomebottom-up not just in terms of informationgeneration, but also in informationdissemination and linkage with other processes,particularly the quarterly monitoring reviewprocess. In addition, specific technicalassessments in problem hot spot areas could becarried out during the year, to feed into the JRM

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process as opposed to having these all done atthe JRM.

Improving monitoringw Endorse the M&E strategic roadmap to give

overall comprehensive guidance to strengthen-ing of the M&E function in the sector.

w Develop TORs for elaboration of a developmentroadmap for agreeing and reassigning roles andresponsibilities across the sector, staffing,system design arrangements, equipping,training and financing plan. It also includesdevelopment or updating of a national healthinformation policy and regulations and adjustany existing guidelines to comply

w Set up a national representative healthinformation technical committee that will notonly to drive this work but give technicaloversight to ensuring the M&E strategicframework is implemented in a comprehensiveand participatory manner.

w Establish a focal point on health research as afirst step towards building capacity for essentialhealth research policy development, operationsresearch and collaboration with researchinstitutions for health improvements.

Improving public procurementw Accelerate the implementation of the

procurement improvement planw Delineate procurement responsibilities between

the ministry PU and other procurementorganization including KEMSA.

w Establish the various committees currentlypending(NMTC).

w Complete the new comprehensive pharmaceu-tical policy.

w Urgently embark on capacity building inprocurement and accountability.

Strengthening commodity supply managementw Delineate roles and responsibilities of MOH and

KEMSA, and define the role of KEMSA vis-à-vis non public actors like MEDS.

w Demonstrate support KEMSA by articulatingclear plan and schedule for transferring thebalance of its EMMS procurement andeventually medical equipment to KEMSA.

w Implement 5% of handling charges for allcommodities procured by third parties anddistributed through KEMSA.

w For KESMA, provide information to healthfacilities the unspent portion of their quarterlydrawing rights and roll it over to the nextquarter

w Increase the resources allocated to theprocurement of commodities that goes to thehealth facilities.

w Review the impact of 10/20 policy on FBO andNGO facilities and consider grants to allow thesefacilities to drawing rights from KEMSA.

w Build capacity at all levels.w Finalize the revision of National Pharmaceutical

sector strategic plan.w Revise Essential medicines list.w Scale up demand driven supply system.w Introduce quality assurance mechanism

(including regular audit) for commodities andsupplies.

Enhancing investment and maintenancew Strengthen the strategic framework to guide

investment in infrastructure , communicationand transport.

w Develop an ICT implementation plan to guideinvestment in the health sector.

w Improve financing of maintenance of infrastruc-ture, health facility plant, equipment andtransport to ensure the sound state of theiroperation.

w A communication and transport strategy shouldbe developed to improve and rationalize supportto referral

w Develop the capacity for maintenance.

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In its aspiration to reverse the observeddownwards spiral of the health indexes,NHSSPII recognizes that to effectively do so,there is need to involve all sector players and

the population at large in decision making. ThePlan’s intention is to establish a well functioninghealth system that relies on collaboration andpartnership with all stakeholders whose policies andservices have an impact on health outcomes.

One of the four sector priorities provided for inthe Joint Programme of Work and Funding is thestrengthening of sector stewardship and partner-ships with all stakeholders by ensuring clarity ofroles and responsibility in a rationalized organiza-tional setting and instituting joint planning, fundingand monitoring arrangements. The mechanism forputting this into operation is a programme toreview and reform existing common arrangements(CMAs) with all stakeholders to conform to an agreedSWAp and other international declarations oragreements. These consultations would inform thesigning of a Code of Conduct and subsequently aJoint Funding Arrangement.

Joint Planning and PrioritySetting

Functional planning calendar: In line with thestrategic plan, a formal planning andmonitoring system and calendar has been

introduced and functional in the last two years. Mostof the stakeholders are part of the process. Moreover,there are still development and implementingpartners that are planning and budgeting on projectmode and outside the agreed time frame. The followup and reporting of adherence to the COC principleswill assist in providing incentive for better alignmentif the results are widely shared to ensure that thereis also peer pressure among these actors.

5. Progress with Objective 4: FosteringPartnership

Several strategies were proposed to implementthis component which has been implemented tovaried degrees. Three annual operational plans(AOPs) have been developed and utilized during theperiod of the current NHSSP. The first AOP wasdeveloped in tandem with NHSSP II on the basis ofcontributions of mainly national public sectorplayers and hence had limited participation,ownership and awareness. The Plan was notlaunched because the launch of NHSSP II occurredsix months (29 March 2006) after the JICC approvalin September 2005. Non the less, the plan becamethe key guide for the national interventions to laythe foundation for design of SWAp, which wasexpedited through the government-wide RRI. Thesecond AOP was developed in tandem with JointProgramme of Work and Funding (JPWF) basedon inputs of SWAp RRI groups that formulateddocuments addressing priority areas on KEPH andKEPH support system as well as the contributionof district and provincial plans that was developedthrough a bottom up approach.

The key principles of developing both the secondAOP and the JPWF were a product of a consultativeforum of key sector stakeholders held in October2005.18 Key amongst the principles for AOP 2development was for the Ministry to initiate aprocess for a bottom-up planning process. This beingthe first attempt of country wide bottom-up planningthrough involvement of districts in determining

18 Kenya Health SWAp Concept Paper, 2005,www.hsrs.health.go.ke

Building stronger partnerships andstrengthening stewardship involves ensuringthe clarity of stakeholder roles andresponsibilities in a rationalized organizationalsetting characterized by joint planning,funding and monitoring arrangements.

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their planned outputs and interventions for eachpriority areas and established targets, the outcomewas very encouraging. In total, 78 (including 39final ones) district health plans and 5 provincialplans were submitted and included in AOP 2. Thisprogress was not without challenges, such as theinclusion of individual facilities, private sector,district governance structures and department/division wide participation. A major constraintduring the development of AOP 2 was the limitedlink between the plan and the funds through MTEFand funds outside the printed estimates. Thischallenge notwithstanding, AOP 2 became the basisof the PS’s performance contracts and those of thecascaded contracts.

The challenges faced in developing the secondAOP informed the process and design of the thirdAOP. The sector decision that AOP 3 needed to bedeveloped on the basis of the MTEF in turn posedtwo significant challenges:w It delayed the district, provincial and national

planning and the required quality control(support only started end-March afterdeclaration of the resource envelope in mid-March) and operations allocations for DHMTand national divisions/programmes were notconcluded at the time of conclusion of the plan;and

w The alignment of priorities and objectives ofNHSSP II and JPWF were not necessarilyaligned with the budget structure under theMTEF and failed to reflect the overall resourceflow that is coming to the sector.

These constraints and challenges have providedan opportunity for the sector to critically examinethe structure of the MTEF and agree on anfunctional budget that has been called a “shadowbudget” to enable the sector to factor a functionalstructure and include all on and out of budget funds.Further, this experience has justified the need tostart the planning process in first quarter ratherthan in the third quarter as has been the process todetermine the available resources for all levels fromthe different sources to better inform resource-basedplanning. As explained in the planning section,however, there is lot of preparatory work to becompleted by government, implementation anddevelopment partners for the effectiveness of thefunctional budget.

The participation of implementing units in theplanning process has increased substantially duringthe last three years (from AOP 1 to AOP 2 and nowduring AOP 3 preparations). In AOP 3 there is nowfull compliance by all districts, provinces andnational programmes/divisions to an agreedstandard format and adherence to a consolidatedplanning process. In terms of participation, whatremains is the inclusion of levels 5 and 6 (provincialand national hospitals) in the planning process.

These experiences will be invaluable for thedevelopment of AOP 4 and improvement of thegeneral planning process. AOP 3 plannedstrengthening of the district governance structureswill further enhance stakeholder participation injoint planning at the lowest level of care-community.

The government-wide initiative of performancecontracts and performance appraisal systems, whichhave been institutionalized and are at formativestages, have been valuable instruments forinstitutionalizing AOP 2 to inform the indicatorsand targets that are then utilized for generatingand negotiating performance contracts. This equallywill in future be strengthened by the currentperformance appraisal system in the public sectorthat requires each individual to be appraised everysix months on key outputs drawn from the AOP.

There are still challenges that sector shouldimprove further in the area of planning:w Ensuring that the quality of plans at all levels

(by facilities, districts, provinces, divisions,implementing agencies and developmentpartners) have improved and interlinked tosupport each other. Significant activity is stillbeing implemented not only outside the budgetbut also outside the mainstream annual plan.

w Ensuring the predictability of resources fromall sources and linking them to the strategicobjectives and priorities of the sector. There isa need for a transparent resource allocationmechanism to ensure that allocative efficiencyis achieved.

The quality and scope of sector-wide planninghas been consistently and systematically improvedas a result of the strengthening of the sectorcoordination mechanisms, key of which is theestablishment of the Health Sector CoordinatingCommittee (HSCC)19 which now occupies its policyleadership role from the third quarter of AOP 2augmented by the improved stewardship role of theMinistry of Health. The HSCC establishment is akey milestone in institutionalizing the Kenya HealthSWAp (KHSWAp) as it is expected to not onlycoordinate joint planning and monitoring but to alsosteer the establishment and strengthening of thesector coordination structures and mechanismsincluding reforming the ICCs and District HealthStakeholder Forums (DHSF).

NHSSP II provided for an annual HealthPlanning Summit that serves as the zenith of theplanning process for the following year, where thekey dissemination and launch of the sector plan isconducted. Two Planning Summits have been held,in June 2006 and 2007, that have helped to increaseownership and awareness of the AOPs across thesector. Some districts are report as having launchedtheir AOPs (which are the District Health Plans)

19 Health Sector Coordinating Committee (HSCC) TORs(approved), www.hsrs.health.go.ke

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in their districts after the June 2007 national launch.The launches have been held in June rather thanthe desired May because of lateness in thepreparation of the AOP, which hopefully will becorrected through initiation of the process in thefirst quarter of the year.

Joint Monitoring

NHSSP II recognized joint monitoring as oneof the critical pillars of the KHSWAp andhence proposed an annual Health Review

Summit in November as the zenith of a reviewprocess where the sector performance isdisseminated and the report is launched. It alsoproposed the strengthening of a uniform healthmanagement information system for the sector.

The performance monitoring system aimed atsupporting the health managers through providingaccurate and timely evidences for decision making.During the time of NHSSP II, there are positivedevelopments in this area. These include theintroduction of result based management, theintroduction of quarterly performance report andthe production of annual reports.

The result based management systemsintroduced particularly the rapid results initiativehave fast tracked the implementation of some ofareas. It helped to speed up the development ofSWAp processes. It also assisted in improving servicedelivery at district levels: ART, immunization arebest examples in this regard. The main innovationof the RRI initiative is defining goals, millstonesand actions steps and conducting close follow up bythe top management on the realization of the settargets. The lessons leant in the RRI initiative, ifscaled up to the regular quarterly reviews to ensurethe realization of the implementation of AOP targets,it will positively contribute to reversing the trends.

Performance reports, JRM and the annualhealth summits: One of the cornerstones of SWApis the institutionalization of common monitoringmechanism to reduce the over elaborate andrepetitive project based implementation reviewscarried out by individual projects and programmes

For the first time, the MOH released acomprehensive Health Sector Performance reportthat reviewed the achievements, constraints andchallenges during the first year (2005/06) of thecurrent five-years plan period, against the objectivesand the targets that had been set in AOP 1. In spiteof its limitations, as outlined in the report andcommented by independent of consultants, it hasprovided the platform for future policy dialogues.

The most important outcome of the firstperformance report was the ranking of the districtperformance, though the methodology needs to berefined, to create a sense of result orientation(delivered services per unit of input) or value for

money and a feedback mechanism. The exerciseresulted in a ranking of 61 districts (out of 78) andthe selection and acknowledgement of the bestperforming district in each of the eight provincesThe best performing districts at provincial andnational levels were acknowledged. Similarly, thebest performing districts in the first nationwiderapid results initiative were also identified anddocumented. This has created a sense of competitionfor recognition and improved the reporting rate asnon reporting districts are classified last in ranking.Some districts did discuss their performance withtheir stakeholders afterwards.

The joint review mission carried out by theindependent consultants created a forum where theweaknesses in the implementation of plannedactivities and actions to improve them are openlydiscussed by sector partners agreed and takenforward for the ongoing and next AOPs. Theindependent consultant provided valuable inputs forimproving the various areas of the work plan. Therewere lessons learnt in the planning and manage-ment of future JRMs (preparation, length of time,support required, etc) from the fist experience. Thejoint review mission of 2007 is expected to reviewthe extent to which the recommendations of the JRM2006 have been implemented.

The results of the performance report and theJRM mission was discussed in the JRM meeting inOctober 2006 where major forward looking actionswere agreed. As per the planning cycle adopted bystakeholders, the first review health summit wasconducted in a one-day meeting on 30 November2006, in Nairobi, attended by delegates from almostall the actors that have a stake in the health sectorin Kenya (district health management teams fromall over the country, senior officials from the MOH,civil society representatives, senior governmentofficials, the donor community, the MOH reiteratedits intentions and achievements in reforming thehealth sector and gave a rather detailed insight intowhat had been achieved so far. The health planning(June) and monitoring (November) summits are nowfirmly instituted. The way the summit conductsits business could be strengthened further.

The reports are prepared at high transactioncost, as there is as yet no single custodian ofinformation in the Ministry

Pooling of Funds

A Code of Conduct signed by key partners tothe sector forms the base for designing anagreed fund, in tandem with the Joint

Funding Agreement development, which wouldprovide the guide for the day-to-day management ofresources. Consultations by the different partnersare on-going that will inform the design.

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Stewardship, Leadership

Strategies for strengthening governance andmanagement, overall health legislation,regulation and law enforcement systems, and

partnerships with stakeholders were all part ofNHSSP II. These aims supported the restructuringof the sector in order to improve servide delivery.

Several consultations on the restructuring havebeen conducted and are still going on. In addition,under the leadership of MOH, and in closecollaboration of the development and implementingpartners, members of the sector developed andsigned the Code of Conduct (COC). Development andimplementing partners will be required to buy intothe health sector programme of work and plans.

Governance and management structures arebeing strengthened. The key focus is on aligningthe existing structure to KEPH. A stewardship andcoordination structure20 was developed as aframework whose details are being developed toinitiate implementation. The governance structureframework21 was further developed to link theformal and informal delivery health deliverystructures up to the household level. Draftgovernance tools have been revised to make themcompliant to KEPH and their utilization will occurfrom Q2 of AOP 3.

Health service provision in the city of Nairobihas been reorganized through the establishment in2003 of one Health Management Board and eightDistricts, each with its own DHMT. PMO Nairobiis the Chief Executive Officer (CEO) of the Board.MOH has also strengthened the services throughthe provision of Doctors, Nurses and Public HealthTechnicians. These health districts are currentlybeing linked to the three newly constitutedadministrative districts. At the moment, these 8districts are severely constrained by inadequate anddilapidated infrastructure.

The MOH is fostering greater ownership ofhealth services by communities through a numberof strategies. One is through popular participationin the coordination, planning, managing andmonitoring of health services. A number of forumshave been set up from the village to the provinciallevel to foster this ownership, including villagehealth committees (VHC), Health FacilityCommittees (HFC), District Health ManagementBoards (DHMB), District Hospital Boards (DHB)and the District Health Stakeholders Forum(DHSF). Not all these committees are fullyfunctional and there is a need to provide continuing

support to build their capacity and understandingof their roles and responsibilities. The MOH isincreasing ownership of the health services throughempowerment of the community and the individualsit serves. It has also developed a Service Charter,which was launched by His Excellency, thePresident Hon. Mwai Kibaki on 22 January 2007.The Service Charter recognizes the community ascustomers with rights and as claimants withlegitimate demands on the health service. Cascadingservice charters to the health facility level will bean enormous challenge, but is a key deliverable inmost performance contracts.

As for legislation reviewed and gaps identified,no progress has been made in delivery of this output.Consultations are ongoing to fast-track the process.

Dialogue dialogue with private-not-for profit hasbeen systematic and encouraging through theirincorporation as a third major partner to the signedCode of Conduct, which now forms the frameworkof partnership. The Kenya Episcopal ConferenceCatholic Secretariat (KEC-CS) and Christian HealthAssociation of Kenya (CHAK) coordinate the bulkof not-for-profit non-government health careproviders. Following high level meetings inSeptember 2006, these bodies have re-openeddiscussions with MOH to suggest modalities forfuture collaboration, including the re-instatementof a financial grant to church health facilities;secondment of doctors and nurses; support in kindthrough provision of drugs, medical supplies,equipment and ambulances, and the revision andupdating of the legal policy framework to governthis collaboration.

This dialogue was greatly improved by theestablishment of a network for the NGOs and FBOsin health to facilitate effective dialogue within thesector. The challenge is to facilitate a similarnetwork to enable engagement with the private-for-profit sector whose initial dialogue was initiated inQ4 of AOP 2 and is expected to be further dependedin AOP 3.

Formal partnership arrangements are routine:Having designed the KHSWAp during 2005/06,focus during AOP 2 was on development of theSWAp instruments from the first quarter (Q1). Anagreed draft COC22 was concluded by AOP2 in thethird quarter and agreed that a key partner – theMinistry of Finance – would countersign theinstrument and facilitate the signing of the otherpartners. The COC was signed on 2 August 2007 atthe Treasury by the Permanent Secretaries of theMinistry of Health and Ministry of Finance and 11sector partners. The Ministry of Finance willcoordinate the completion Joint Funding Agreement(JFA) development from AOP 3 Q1 to guide effectivesystem development for quality service deliver.

20 Ministry of Health, Joint Programme of Work andFunding for the Kenya Health Sector 2006–2010, pp54–5, www.hsrs.health.go.ke21 Ministry of Health, Community Strategy Implementa-tion Framework, 2006, www.hsrs.health.go.ke

22 Kenya Health SWAp: Code of Conduct, 2007,www.hsrs.health.go.ke

36

Recommendations to ImproveCollaboration and Partnership

Considrable progress has been made towardsthis objective, but improvement is neededin some areas, as itemized below. Issues of

efficiency, equity and effectiveness are addressedunder objectives one and three.w Develop a roadmap for advancing the Kenya

Health SWAp and governance structures forannual planning to be agreed and HSCCmandated to monitor its progress.

w Articulate clear benchmarks to ensureadherence by all parties to the COC and ensurethe SWAp is advanced.

w Formulate a public-private partnership policyframework, but give priority to addressingissues relating to private not-for-profit providersinvolved in direct service provision.

w Set national targets for indicators of progresson aid effectiveness per the Paris Declaration(ownership and leadership, alignment togovernment strategies and priorities as well assystems, mutual accountability for results andharmonization) within the NHSSP II M&Eframework and to inform the KJAS resultsmatrix.

37

One of the targets set out in the EconomicRecovery Strategy was to achievea 5% reduction in poverty by 2007.Health was given prominence in the

ERS and was seen as an important contributor tothe efforts to reduce poverty, as well as overalleconomic growth and development. The ERS notedthat the system of charging fees for services hadresulted in up to 40% of the poor not seeking carebecause they were unable to pay. At the same time,the plan noted that apart from barriers because ofcharges for services, the poor state of healthinfrastructure and shortages of essential drugs,among other factors, further contributed to theunavailability and low population coverage of healthservices. Consequently, introduction of NSHIF,rehabilitation of health facilities, and adequatesupply of drugs in health facilities were singled outin the strategy as important measures to improvethe availability of health services and thereforecoverage and access.

In addition to defining health care accessindicators, the ERS also set targets related tofinancing for health care, and committed to increase:public sector per capita expenditure on health fromUS$6.5 to US$10 by 2007; allocation for drugs andmedical supplies to 16% of the health budget; andoverall GOK funding on health from 5.5% of totalpublic expenditures to 12% between 2003 and 2013.

Developed in this context and introduced soonafter the launch of the ERS, NHSSP II planned toachieve the following resource-related objectives:w To improve the availability of more resources

for health in a sustainable and equitable mannerw Review health financing mechanisms

specifically to introduce NSHIF to graduallyachieve Universal population coverage

w Reorient and re-focus public investments forhealth care provision to benefit the poor moreby reallocation of resources towards promotive,preventive and basic health services

6. Progress with Objective 5: ImprovingFinancing of the Health Sector

Assumptions

Achieving increased financing for health waslinked to a set of inter-related events anddecisions at the macroeconomic and

government-wide level, health sector-specificdecisions as well as health-related initiatives at theinternational level.

The ERS projections indicated that Kenya wouldachieve the following macroeconomic indicators:w GDP growth rate of: 1.2% in 2002; 1.9% in 2003;

and reaching 4.3% in 2006/07 period;w Reduction in poverty by 5%; andw Improved economic management for example a

lowering of the wage bill.

Achieving these targets would result inincreased GOK spending on health through theallocation of additional resources, and also throughbetter management of the wage bill to createspending flexibility to allow increased allocation ofavailable resources to previously under funded butcritical inputs for service delivery.

Several methods of financing health servicesare available, including taxation, user fees,donor funds and health insurance. Thesemethods have become increasingly importantfunding mechanisms for funding healthservices in the country, but they should reflectboth the cost of service provision and thepopulation’s ability to pay. Governmentresources fall short of Kenya’s commitmentto spend 15% of total budget on health, asagreed in the Abuja Declaration, thusreducing the sector’s ability to ensure andadequate level of service provision to thepopulation.

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Increased Government Allocationsto Health

The government through its budget outlook paper(BOPA) and budget strategy paper (BSP) 2003–2007/08 committed to gradually increase healthspending to facilitate greater access to better qualityhealth care by improving the provision of drugs,more staff training, etc.

The spending ceilings were set to change asfollows:w Sector ceiling for health as a percentage of total

GOK was to grow from 8.62% in 2004/05 to9.90% in 2005/06, 10.30% in 2006/07, and10.67% in 2007/08.

w Ministerial ceiling, on the other hand, was togrow as a ratio of government expenditures:7.66% in 2004/05, 9.09% in 2005/06 and 9.32%in 2006/07.

These projections meant that public expenditureon health would grow both absolutely and inproportion to GDP and overall governmentexpenditures, as well as in per capita terms.

Rise in User-Fee Revenues (PublicHealth Facilities)Revenues from user fees were kept modest to reflectthe trend in revenue yield reported by GOK healthfacilities, and also on projections from the strategicplans of Kenyatta National Hospital (KNH) and MoiTeaching and Referral Hospital (MTRH).

Rise in Bilateral and MultilateralFinancial Assistance

The revenue yield from external resources (donorassistance) was calculated using the 2002 NationalHealth Account (NHA) estimates of donor fundingon health in Kenya, and adjusted to reflect theexpected pattern of external funding as depicted inthe analysis by the External Resources Department(ERD) at the Treasury as well as to reflect potentialgrowth in funding resulting from the new globalinitiatives for health.

In the base case scenario, public expenditureswere expected to increase as a proportion of GOKand reach a level of 8.6% in 2005/06, and rise to10.7% in 2007/08. Funding streams based on thisscenario are summarized in Table 6.1. A secondscenario assumed an increased level of externalresources and a higher level of GOK allocation onhealth at levels commensurate with the goal ofreaching the ERS target of 12% as a share of totalgovernment expenditure (Table 6.2).

Table 6.1: Scenario 1 projected funding onhealth (million Ksh)

Funding 2005/ 2006/ 2007/ 2008/ 2009/source 06 07 08 09 10

GOK 26,384 34,014 39,585 45,384 52,835User fees 2,729 3,152 3,648 4,233 4,923Donor 4,910 5,277 2,703 2,716 2,869NSHIF 0 0 11,515 11,611 15,138Total all

sources 34,023 42,443 57,451 63,944 75,765

Table 6.2: Scenario 2: projected funding onhealth

Funding 2005/ 2006/ 2007/ 2008/ 2009/source 06 07 08 09 10

GOK 34,635 40,203 45,217 50,606 56,611User fees 2,729 3,152 3,648 4,233 4,923Donor 4,910 5,277 2,703 2,716 2,869NSHIF 0 0 11,515 11,611 15,138Total all

sources 42,274 48,632 63,082 69,166 79,541

Analysis of Performance

There has been an increase in nominalaggregate and per capita public spending onhealth for both approved and actual

expenditures during the last two years Approvedallocations increased by 52% between 2004/05 and2006/07; and annually by 26% between 2004/05 and2005/06, and about 20% from 2005/06 to 2006/07.

Table 6.3 summarizes the trend in publicspending on health. The increased spending isreflected in the rise in per capita spending in bothallocations and actual spending. The level of percapita public spending on health increased fromUS$8.7 in 2004/05 to US$14.5 in 2006/07 in thecase of approved budget, and from US$7.6 in 2004/05 to US$10.0 in the case of actual expenditures.

Table 6.3: Trend in public expenditures onhealth

 

2004/05 2005/06 2006/07

Approved budget* 21,977 27,832 33,526Approved US$ per capita 8.7 10.8 14.5Share of total govern-

ment expenditure (% ) 7.24 7.27 7.27Share of GDP (%) 1.71 1.78 1.91Actual expenditure* 19,158.40 20,636.00 23,178.00Actual US$ per capita 7.6 8.0 10.0Share of total govern-

ment expenditure (%) 6.31 5.39 5.02Share of GDP (%) 1.49 1.32 1.32$/Ksh exchange rate 77.3 77.3 68Population projections

(in millions) 32.8 33.4 34*Ksh million)

39

The share of GOK spending on health remainedlower than the anticipated levels during the period2004/05 and 2006/07, the allocations (in absoluteterms) appeared to match the level of resource yieldprojected for this period. For example, publicspending on health was projected to reach Kh34.023billion in 2005/06 and Ksh42.443 billion in 2006/07under enhanced allocations to health as proportionof GOK expenditures.

As Table 6.4 shows, the current levels ofbudgetary allocations are not too far off theprojections, accounting for up to 80% of the projectedresource yield, at least in 2005/06 (under a higherGOK allocations and a scenario of modest user feesand donor contributions).

Table 6.4: Estimated available resources vs.projected flows

2005/06 2006/07

Projections (scenario 1) 34,023 42,443Projections (scenario 2) 42,274 48,632Available budgetary (allocations) 27,832 33,526Available resources (all sources) 42,074 46,619

Because of macroeconomic factors, and thegovernment’s intention to limit its expenditures toa manage level of GDP, it is unlikely that substan-tial increases in budgetary resources allocations tohealth can be expected.

Per capita health spending

Mobilizing and coordinating the use of all availableresources, including off budget support, wouldimprove the financing of the sector. Such coordina-tion would have placed nominal per capita spendingon health at US$17.6, US$21.5 and US$23.7,respectively, in 2004/05, 2005/06 and 2006/07, andmade spending in the sector close to reaching therequired per capita expenditures for providingKEPH services.

Trends in per capita expenditures aresummarized inTable 6.5 and illustrated in Figure6.1.

Table 6.5: Per capita health spending inKenya compared with selectedbenchmarks (US$)

  2004/05 2005/06 2006/07

All sources 17.6 21.6 23.7approved budgetary only 9.57 11.9 14KEPH requirement 25.8 25.8 28.8KEPH and Non-KEPH 36.9 36.9 41.2WDR 1993 12 12 12WHO 2000 35 35 35

Actual Expenditures Compared withApproved Budgets

Approved budgets constitute a road map for thespending in a given financial year. Actualexpenditures reports released every year reveal thetrue allocations and their applications inimplementing planned activities. A review ofexpenditures during 2004/05 and 2006/07 revealsthat the variance between aggregate approvedbudget and actual spending is decreasing inpercentage terms from 87% in 2004/05, to 74% in2005/06, and to 69% in 2006/07 (see Figure 6.2 forthe trend).

Issues in Public Spending onHealth

More importantly, the low level of spendingshows that little progress is beingmade towards meeting the government’s

own expenditure targets, which were set to increasefrom 7.66% in 2004/05 to 9.32% of total governmentexpenditures in 2006/07. These low levels mean thatpublic spending will not only stay below the ERStarget of 12% of total government spending, but also

Figure 6.2: Approved and actual expenditurescompared

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

2004/05 2005/06 2006/07

Year

Bill

ions

of K

sh

Approved budgetActual expenditure

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

2004/05

2005/06

2006/07 Year

US

$ p

er c

apit

a All sourceapproved budgetary only KEPH requirement KEPH and Non-KEPH WDR 1993 WHO 2000

Figure 6.1: Per capita spending on healthagainst selected benchmarks

40

not approach the 15% commitment reached atAbuja, as well as other international spendingbenchmarks – US$35 (recommended by WHO).

Budgeting and expenditure reforms – involvingthe use of budget ceilings were introduced to helpachieve fiscal discipline, which links expendituresto macro-economic forecasts – GDP, inflation,balance of payments, revenues, and aggregate levelsof expenditures. The BOPA 2007 has applied thisfiscal management framework in setting out theprojections for health sector expenditure scenariofor the period 2007/08 to 2010. The level of MOHexpenditure was expected to increase from Ksh35.0billion in 2006/07, to KShs.38.9 billion in 2007/08to Ksh43.1 billion in 2008/09, and reach Ksh53.0billion in 2009/10.

In general, it appears that decisions regardingexpenditure allocations to health are influencedlargely by decisions and factors outside the sector.As part of the overall strategies to improve healthfinancing, the sector has implemented the followingstrategies to influence the allocation of resource forthe sector.w Developing quality sector plans: The overall

allocation of resources are being done accordingto how the ministries or sector plans respond tothe ERS objectives in particular, in relation tocore poverty programmes. The role of health inpoverty reduction is well recognized. As suchwhat the ministry needs to do is to promote itsstrategic plan and show its core povertyreduction programmes. The AOPs developedannually offer the best opportunity to identifyareas for negotiating for enhanced allocationsto the sector, especially if it is able to identifypriority areas for spending in the sector.

w Accurate and comprehensive costing ofsector plans: This can provide invaluableinformation for lobbying for additional or newfunding to the sector.

w MPER process: Here the intention is tostrengthen dialogue and coordination with MOFand partners. Immediate options available tothe MOH include the use of the MTEF andsector hearings, as well as the use of MPERs todocument spending and areas that requireadditional or new funding.

w Overall sector financing strategy: This isan ongoing effort.

These approaches need to be actively used forinfluencing additional resources from the centralgovernment (MOF, other government offices) andparliamentarians. Several multilateral and bilateraldonors (IDA, DFID, US government agencies,DANIDA, Sida, GTZ-GDC, JICA, UNFPA,UNICEF, UNDP, AfDB, etc.) have showncommitment to support the activities and develop-ments in the health sector in Kenya. An analysisconducted in early 2007 to document current year

and future financial commitments by some of thekey bilateral and multi-lateral partners in the healthsector revealed that a cumulative total of Ksh51.6billion in on- and off-budget support would beavailable to the health sector between 2006/07 and2009/10 period. Traditionally categorized asdevelopment budget, much donor support is usedon items that are recurrent in nature – drugs,personnel, operations and maintenance – and moreso on core poverty and public health interventionssuch as malaria control, HIV/AIDS, immunization,reproductive health, etc.

Even though external resources are animportant part of the overall financing especially ofkey public interventions, inability to predict futureflows of external resources makes planning of servicedelivery difficult and uncertain. Additionally,external resources are prone to shifts in focus – sometimes emanating at the international level, it createsinsecurity in the financing of key health inputs.The health sector in Kenya has experienced thesedifficulties, and increasingly the government istaking decision not to factor donor resources as partits annual budget since the mismatch between donorpledges and commitments has led to the variancesin budget and actual expenditures reported at theend of government financial year.

As evident in how forthcoming most donors werewith information on their planned contribution tothe sector, this is becoming a lesser issue in Kenya.This stems from the on-going inclusivearrangements under the SWAp framework, and theParis Declaration on Aid Effectiveness. Regardless,existence of a large amount of resources off-budgetremains a challenge to monitor the utilization ofthese resources.

External aid flows can impinge on the sector’sfiscal space and present a challenge to theachievement of fiscal management goals of thegovernment. A good example is the use of donor aidto support the hiring of health personnel in somecadres to address the shortages. As a result, theMOH will be forced to seek additional funding toabsorb these personnel upon the expiry of theircontracts following the lapse of donor support. Theuse of these funds to sustain these additional staffimpinges on funding for other activities.

Alternative and InnovativeFinancing Mechanisms

Clearly, additional approaches are needed toindentifying resources to finance health carein Kenya. The approaches range from a

fresh look at existing sources, like user fees andNHIF, to the adoption and adaptation of novelmechanisms for generating funds

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User Fees

The system of user fees for health care wasintroduced in the public sector in Kenya in 1989against the background of decline in budgetaryallocations to health resulting from the drop inoverall government expenditures experienced at thetime. The drop and low budgetary allocations tohealth resulted in lack of essential supplies forprovision of care and manifested in non-availabilityand poor quality services.

Though modest, the revenues from user feeshave formed an important source of discretionaryexpenditures in public health facilities. In its earlyphase, revenues from user fees accounted for up to37% non-staff expenditures in provincial hospitals,and about 20% at lower hospitals, and 21% in healthcentres.

More recently, user fee revenues collected inpublic hospitals have increased, although in amodest way, and are helping to finance gaps inresource requirements in public health facilities.Within individual health facilities, user fee revenuesare significant and form an important source ofdiscretionary spending for O&M, and sometimesbecame an important source of expenditures foressential medical supplies because of both the under-allocation centrally for these items, and theinflexibility in the management of the MOH budgetat the local levels (10/20 Policy Review Report, 2005).

Recent data on the programme show somegrowth in the amount of revenues collected andreported by MOH health facilities. Analysis doneas part of the MPER-Health 2006 reported thatthese revenues accounted for up to 7.4% of MOHrecurrent expenditures for 2005/06.

It appears that there is some role for user feesas a mechanism for health financing in Kenya.Realizing its full potential is curtailed, largelybecause of the lack of third party payment for thecost of waivers and exemptions instituted to protectand guarantee access by the needy. As a result, thefee levels were kept low, thereby undermining itsrevenue generating potential, and consequently itsability to support increased provision and availabilityof quality services.

The success or failure of the scheme in Kenyais a question for debate. As in all health systems, asystem of paying for services – such as introducinguser fees for health – regardless of the level of feescharged, has been a source of motivation for staffby bestowing them with discretionary expendituredecisions, as well as creating a mechanism forpricing of health services, which is a foundation fordeveloping and expanding pre-payment schemes,i.e., health insurance, etc.23

National Social Health InsuranceFund

The MOH has increased its efforts to find anaffordable, equitable, effective and efficient healthfinancing system. In view of the stalled process ofthe NSHIF and in line with the vision 2030 of theGovernment, the MOH has established a workinggroup which is developing a health financingstrategy for the next decades.

Social Health Insurance is considered as onepossibility but all other possible combination offinancing systems are also reconsidered.

Presently, Kenya has the oldest social healthinsurance in sub-Saharan Africa The NationalHospital Insurance Fund (NHIF) has been operatingfor more than 40 years and covers the formal sectoragainst cost of admission treatment. While inprevious years the benefits of NHIF were quitelimited and members still had to pay considerableamounts for admission treatment, this has changedrecently. Over the last 3–4 years, the services ofNHIF have been improved drastically in order tomake the impact of the insurance coverage felt tothe members.

Meanwhile, NHIF is collecting contributionsfrom its members up to the equivalent of 20% of theHealth Ministries’ recurrent budget allocation. Evenso, the ratio between the revenue collected and thebenefits paid for members’ treatment is 40–50%,still far below international standards.

Among the issues to consider here are:w NHIF contribution to the health sector not

covered in MOH planning.w Contributions from members of NHIF is not

equitable as it comprises of fixed rates and notpercentages.

w Surplus from NHIF used erratically tosubsidize public health services.

w NHIF benefit ratio too low by all standards.w Untapped capacity in NHIF for output based

health financing, contracting especially withprivate sector and quality management/improvement.

Other Financing Mechanisms

The MOH is further testing various tools for healthcare financing in order to learn from their impacton service provision, quality development andimprovement of access. Alternative exemptionmechanisms and identification tools for the poor arealso piloted in various districts.

A so-called “output-based aid” (OBA) approachtries to establish the impact of a voucher systemthat provides the target group with access toreproductive health services. Identified poor women(target group) can purchase vouchers for familyplanning, antenatal care and delivery or gender

23 World Bank, Health Financing Revisited, 2006.

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based violence (e.g., rape) at a highly subsidized rateand request the services from selected accreditedservice providers. The hospitals, health centres anddispensaries receive the actual payment for theservices from a financial management agent uponsubmission of the vouchers at a previously agreedrate.

All reports from the three districts and twourban slums in Nairobi where the programme hasbeen operating for almost two years indicate thatthe utilization of reproductive health services by thetarget group has increased dramatically. Financialflow to both government and non-governmenthealth service providers is smooth and effective.

Furthermore, the MOH is testing a system of“social franchising” where selected private healthservice provider are supported and trained theprovision of good quality long term contraceptivemethods which in turn is provided at a subsidizedrate.

Issues to consider in this approach include:w OBA implementation still under Ministry of

Planning.w Results of revision of pilots not widely known.w Limitation of pilots to reproductive health.

Improving the Allocative Efficiency

One of the objectives of the NHSSP II therefore isto reorient and focus public investments for healthcare provision to benefit the poor more byreallocation of resources towards promotive andpreventive services, and basic health services. TheMOH has made positive steps in reorienting itsbudget and expenditures to support the policyobjectives of making the budgeting and financingof health care pro-poor.

As shown in tables 6.6 and 6.7, there has beena gradual reduction of the budget allocated tocurative health as a proportion of the total MOHrecurrent budget. The level reduced from 45.9% ofactual expenditures in 2004/05 to 38.1% in 2005/06, representing a 20% reduction below the previousyear expenditures.

Table 6.6: Trends in expenditures aspercentage of total MOH budget

Function 2002/03 2003/042004/05 2005/06or service Actual Actual Actual Actual

Curative 50.8 48.5 45.9 38.1Preventive/promotive 5.3 5.8 9 17.4Rural health services 10.6 13 13.1 17.8KNH 15.2 14.7 13.9 13MTRH 2.7 2.8 2.4 2.6

Table 6.7: Distribution of MOH recurrentbudget allocation by economiccategories (percentage)

  2004/05 2005/06 2006/07Categories Approved Approved Approved

estimates estimates estimates

Salaries & wages 51.2 54.3 49.4Grants 9.1 7.3Drugs 11.3 11.5 15.2O&M 10.1 10.7 11.9KNH 15.2 14.9 13.4MTRH 2.6 3.7 3.3

On the other hand, preventive and promotiveservices and rural health services have receivedincreased allocations between 2004/05 and 2006/07period. Similarly, allocations for drugs haveincreased to about 15% of the total MOH recurrentbudget, up from 11% level in 2004/05.

Reallocation of resources by levels of care wasanother objective of NHSSP II. In particular, it wasenvisaged that more resources would be allocatedto lower levels – levels 1 to 4 – consistent with theKEPH framework. Table 6.8 shows that Districtand rural health services have been allocated thelargest share of the total resources, mainly humanresources and infrastructure. Although theallocations for drugs and other supplies wereconcentrated at the national level, it reflects thecentralized system of procurement of these items,rather than the fact that they are being consumed

Table 6.8: 2006/07 MOH budget (gross) disaggregated by levels (Ksh million)

Level Salaries & O&M Drugs & Infra. & Grants & Total % ofwages supplies equipment transfers total

Central/National 1,049.40 1,048.70 5,575.20 10 0 7,683.50 24.3Provincial 2,796.10 198.8 256.9 230.5 0 3,482.40 11.0District Health Services 5,940.90 1,066.70 564 980.2 0 8,552.00 27.0Rural Health Services 759.8 697.4 1,958.90 2,408.40 0 5,824.50 18.4KNH 0 0 0 2,858.00 2,858.00 9.0MTRH 0 0 0 714 714 2.3KMTC 0 0 0 60 592.7 652.7 2.1KEMRI 0 0 0 624 852.2 1,476.20 4.7KEMSA 0 119.8 114 108 0 341.8 1.1Total 10,546.40 3,131.50 8,469.20 4,421.10 5,017.00 31,585.40 100.0

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at the centre. It also reflects the fact that the centrallevel still retains a lot of processing responsibilityand power.

Recommendations to Improvethe Financing of the Sector

In an atmosphere of high population growth,widespread poverty and diminished financialresources for health, greater attention needs to

be given both to finding new sources of funds orensuring the precision tuning of allocations ofexisting funds. Among others, the following stepsare needed:w Increase the level of health financing through

improved lobbying for adherence of GOK budgetprojections and donor commitments.

w Improve budget management and exploremechanisms for efficient and equitable resourceallocation and utilization.

w Finalize and implement a long-term healthfinancing strategy.

w Review NHIF Act to adjust the benefit ratio toa minimum of 80%; limit administrativespending; mandate expansion of the benefitpackage to outpatient services; change thecontribution to a percentage/ratio of salaryinstead of fixed rates; and regulate non-benefitpayments/contributions to the health sector.

w Incorporate NHIF spending/income from NHIFreimbursement into financial planning of sectorand health institutions.

w Plan for use of NHIF experience and capacityin contracting, payment of providers/reimbursement for delivered KEPH servicesand quality management.

w Transfer OBA to Ministry of Health.

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References

Republic of Kenya

Ministry of HealthAfya House, Nairobi, KenyaPO Box 30016 - General Post OfficeNairobi 00100, KenyaEmail: secretary@hsrsmoh.go.ke

www.hsrs.health.go.ke