082007 kenyamohper06lastestjan07

Republic of KenyaRepublic of Kenya

Ministry of HealthMinistry of Health

Public Expenditure ReviewPublic Expenditure Review20072007

Printed on: 11 April 2023

Contents

Contents............................................................................................................................i

Abbreviations.............................................................................................................iv

1 Background..........................................................................................................1

1.1 Overall objective of the PER..............................................................1

1.2 Objectives of the Ministry’s PER.....................................................1

1.3 Health Status Indicators......................................................................2

1.4 The Health Services Delivery System..........................................2

1.5 Linkage between ERS, NHSSPII.......................................................4

1.6 NHSSP II - Key principles of AOP2..................................................5

1.7 Strategic issues and policies of the ministry..........................61.7.1 Flow of funds to rural health facilities...........................................61.7.2 Guidelines to financial flow to health centres and dispensaries............................................................................................................81.7.3 Procurement position paper..............................................................8

1.8 MoH Collaboration with the Faith based organisations. 101.8.1 Current collaboration with FBOs....................................................121.8.2 Progress report on MOH/FBHS - TWG on partnership policy Development........................................................................................................121.8.3 Immediate re-instatement of financial grant to church Health facilities....................................................................................................131.8.4 Support in kind through Drugs, Medical Supplies Equipment and Ambulances..................................................................................................141.8.5 Legal Policy Framework....................................................................141.8.6 Donor support to the Health Sector.............................................15

1.9 The Scope and Organization of this Public Expenditure Review.......................................................................................................................15

1.10 The Ministry’s Mission Statement and Core activities 161.10.1 Kenyatta National Hospital..........................................................16

1.10.1.1 Financing........................................................................................181.10.1.2 Impact of Poverty on the hospital.........................................19

1.10.2 Kenya Medical Research Institute (KEMRI)............................201.10.2.1 Achievements...............................................................................20

1.10.3 National Health Insurance Fund................................................211.10.3.1 Financing Hospitals....................................................................22

1.10.4 Kenya Medical Training College (KMTC).................................221.10.5 Kenya Medical Supplies Agency (KEMSA)..............................23

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1.10.6 Moi Teaching and Referral Hospital.........................................241.10.7 Increasing Access............................................................................25

2 Government Spending on Health through the MoH..................25

2.1 Public Spending on Health: Context...........................................25

2.2 Government Spending on Health: Aggregate Levels and Trends........................................................................................................................26

2.2.1 Total Spending on Health.................................................................262.2.2 Recurrent and Development Expenditure................................27

2.2.2.1 Ministry of Health Recurrent Expenditure by Economic Category 272.2.2.2 Ministry of Health Expenditure (Actual) by sub Vote....28

2.2.3 Budget Implementation Actual Expenditures versus Approved Budgets..............................................................................................312.2.4 Appropriations in Aid (AiA) and Cost Sharing ( ).....................372.2.5 Appropriations in Aid (AiA)..............................................................372.2.5 Cost Sharing..............................................................................................38

Table 2.2.7 Total reported revenue collection by province and financial year (KSh million)..............................................................................39

3 3. Review of Projects/Programs related to the Ministry.........................................40

3.1 Core poverty programs.......................................................................40

Table 3.1Summary of projects/programmes in the Ministry, 2003/04- 2006/07....................................................................................................40

3.2 Output/Outcomes related to expenditures.............................41

3.3 Ministry’s On-going Projects...........................................................41

3.4 Stalled Projects........................................................................................46

3.5 New projects TO BE INITIATED IN 2006/07 CHAO TO PROVIDE INFORMATION-CHERUYOIT TO FOLLOW UP – NO NEW PROJECTS SO FAR...............................................................................................47

3.6 Weaknesses in project implementation – Cheruiyot to refer to notes attached to pending bills 05/06................................47

4 Pending Bills......................................................................................................47

5 Analysis of Ministry outputs and corresponding performance indicators.......................................................................................49

5.1 Output targets..........................................................................................49

5.2 Overview of Sector Performance Indicators and Targets50

5.3 Links Budget allocation to Output Delivery...........................51

5.4 Expected Outputs and Outcomes 2006/07..............................52

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5.4.1 Human Resource.................................................................................525.4.2 Drug Procurement..............................................................................525.4.3 Access to ARVs.....................................................................................525.4.4 Restructuring of the Ministry..........................................................535.4.5 Restructuring of Parastatals...........................................................53

6 Public Expenditure Management (PEM)...........................................53

6.1 Budget Preparation Process............................................................54

6.2 Results-Oriented Public Expenditure Management..........556.2.1 Results-Based Management...........................................................56

7 Human Resources Development and Capacity Building.........56

7.1 Service Delivery Inputs.......................................................................57

7.2 Human resources situation..............................................................58

7.3 Human resource disparities.............................................................59

7.4 Impact of HIV/AIDS on Human Resources................................62

8 Implementation of Recommendations of the 2006 PER........62

8.1 Action plans for implementation of 2006 MPER..................62

8.2 Activities and Supporting Actions................................................64

8.3 Timeframes and targets.....................................................................64

9 Challenges and Constraints.....................................................................65

9.1 Integrating NHSSP II and AOPs into the Annual Budget65

9.2 Reviewing Targets.................................................................................66

10 Conclusions and Key Recommendations......................................67

11 Annexes............................................................................................................70

CHERIYOT TO VERIFY- NAMES, % COMPLEION, COST OF COMPLETION (Mr. Gitonga)..............................................................................70

Annex 1: Inventory Of Stalled Building Construction Projects – D11-Ministry Of Health- CHERIYOT TO VERIFY............................70

12 References.........................................................................................................72

Abbreviations

Description

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AIDS Acquired Immune Deficiency Syndrome

CBS Central Bureau of Statistics

GDP Gross Domestic Product

HIV Human Immunodeficiency Virus

MDG Millennium Development Goals

MoH Ministry of Health

NHA National Health Accounts

NHSSP National Health Sector Strategic Plan

PER Public Expenditure Review

PRS Poverty Reduction Strategy

MoF Ministry of Finance

DHMTs District Health management Teams

PHMTs Provincial Health management Teams

FBOs Faith Based Organizations PRSP Poverty Reduction Strategy PaperSARS Severe Acute Respiratory SyndromeHLA Human leukocyte Antigen

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1 Background

1.1 Overall objective of the PER

The overall objective of the PER 2007 is achieving targeted results through efficient public spending.

1.2 Objectives of the Ministry’s PER

The Public Expenditure Review (PER) for health is considered an integral component of the budgeting process and as part of overall economic recovery strategy yet be consistent with the general macroeconomic framework. The overall objective of the review is to assess the extent of public expenditure on health. The specific objectives are as follows:

Present the Government of Kenya's (GoK) policies and objectives in the health sector, and the broad programmes and activities to achieve these over the next three years, annually;

To examine the distribution of public health expenditure by sub vote, and economic categories;

To assess the absorptive capacity of resource in the health sector, To assess the compliance of financial discipline in the health sector; Assess the extent to which the expenditures are aligned to policies

and objectives in the health sector; Review the effectiveness of expenditures; Identify budget related constraints and resource-use; Set out the broad annual financing requirements to implement

planned activities using existing facilities and capacity, but removing short-term constraints while working to eliminate long-term constraints; and

Establish priorities in recognition that there are constraints of financial, technical and physical nature that have to be addressed if the country is to improve its health outcomes.

The efficiency of expenditures as measured by results achieved and their coherence with the sector strategy targets;

The equity of expenditures measured by their contribution to promote more equal distribution of resources;

Budgetary procedures and institutional arrangements.

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1.3 Health Status Indicators

Kenya’s epidemiological and demographic landscape has not changes significantly as the disease pattern is still dominated by communicable diseases. However, lower total fertility rates have been witnessed. Since1993, the number of children born per woman has declined from 6.71

in 1989 to 4.9 in 2003, KDHS (2003), and the infant mortality rate increased from 73 in 1998 to 77 live births by 2004.

Population growth is high by world standards, but has been declining, now estimated at 1.8% per year (Central Bureau of Statistics, 2002) while the contraceptive prevalence rate marginally increased to 41% by 2003 among married women of reproductive age.

Communicable diseases (infectious and parasitic diseases) such as malaria and tuberculosis continue to be prevalent. In addition, diarrhoea diseases, acute respiratory infections, skin diseases and complications of pregnancy are also very commonly seen.

Child malnutrition is reflected in the recent finding (2003) that 20% of children were found to be moderately underweight for their age. On a favourable note, though HIV is still a serious problem its prevalence seems to be declining - now estimated at 6.1%? On the whole, there are wide regional disparities in health status indicators, and significant differences between urban and rural areas [see KDHS].

1.4 The Health Services Delivery System

The Ministry of Public Health (MoH) operates a four-tiered system2 of health care facilities, delivering primary health care in dispensaries and health centres and (Levels 1 and 2) at the locational levels and secondary care at district and provincial hospitals (level 4 and 5), and tertiary care at national referral hospitals (Kenyatta and Moi) (level 6).

However, the system has been characterized by a number of serious problems—many of which are addressed by the NHSSP II and briefly and discussed below.

Limited institutional capacity and lack of financing

1 Excludes the northern part of the country2 See the NHSSP II

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The NHSSP II 2005 – 2010 addresses the problems arising from the weak institutional framework of the health sector, which comprises an under equipped and understaffed public health system and a rapidly growing (and largely unregulated) private sector.

In the past, the MoH has been overly centralized and unable to coordinate effectively its services. The core functions of the MoH are regulation, policy analysis and planning, evaluation and monitoring, and management of service delivery.

The centre (Ministry of Health) largely controls the disbursement systems, while the District Medical officers of Health (DMOH) handles expenditures for the lower levels, sometimes irrespective of their priorities.3 There is, however, decentralization initiative, to devolved authority for spending to rural health facilities (health centres and dispensaries); one effect of this decision will be to minimize opportunities for misallocation of resources as funds will be disbursed directly to them. They in turn will be held accountable for the expenditures incurred.

Efficiency in the allocation of scarce funds: Allocation of funds is highly centralized, and has been directed to health facilities (hospitals, health centres and dispensaries) using resource allocation criteria especially on operations and maintenance.

Overall, the MoH spent about KSh 23 billion ( KSh 19.8 billion on recurrent; KSh 3.2 billion on Development) on health in 2005/06.

Lack of accessibility to facilities for most of the population

was due to limited geographic coverage compounded to some extent by lack of access due to need for cash payments required to receive care: the indirect costs of transportation to facilities are added to the direct costs of paying the fees required for consultations and/or prescription drugs.

1.5 Linkage between ERS, NHSSPII

Acknowledging many of the challenges faced by the health sector, the NHSSP II is an integral part of ERS, from which it is derived identifies several key components of the ERS policy as it relates to the health sector include: 3 See financial flow to health facilities.

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Revisiting the financing of the sector: Introduce the National Social Health Insurance Fund (NSHIF) in a phased approach to eventually achieve universal coverage of free health care for the Kenyan population.

Focusing on investments to benefit the poor: Reallocate resources towards promotive, preventive and basic health services and enlist additional capacity through partnership arrangements.

Increasing cross-sector cooperation: For MOH, strengthen ties and collaboration across sectors in the areas of agriculture, water and sanitation, education, roads, culture and social services, etc.

Increasing efficiency and effectiveness: For MOH, adopt a programmatic approach with all partners involved (sector wide) leading to a jointly agreed strategic plan, financing mechanisms, M&E framework, and procedures for annual sector programme review, together with a jointly agreed medium-term expenditure framework (MTEF).

Increasing GOK funding: Increase health sector funding from the current level of 5.6% of total public expenditure to 12% by the end of the ERS period.

The ERS identifies key policy actions necessary to spur the recovery of the Kenyan economy and is based on four pillars reflecting the overall goals of our society. Firstly, the Government will seek to maintain revenues at above 21 per cent of GDP to enable the bulk of Government expenditures to be financed from tax revenues. Secondly, and more fundamental pillar is strengthening of institutions of governance. The third pillar is rehabilitation and expansion of physical infrastructure and lastly, the fourth pillar is investment in the human capital of the poor.

Addressing health sector, in particular, the ERS identifies crucial efforts like meeting the health challenge through the establishment of a comprehensive National Social Health Insurance Fund (NSHIF) which will provide both in patient and out patient services to all Kenyans; continuing the battle against the HIV/AIDS pandemic by putting in place an integrated approach to prevention, increasing community involvement and ensuring the special health care needs of the infected are met, rehabilitation of existing health facilities; and overhauling

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the system of procurement and distribution of drugs for public health facilities in order to reduce cost of drugs and make them affordable and also to rationalize the distribution system to ensure that drugs are supplied to areas where most needed.

The ERS notes that provision of health services should recognize the people’s needs and lifestyle. In this regard, the existing health facilities have to be made more accessible, properly stocked, staffed and improved in terms of infrastructure and equipment relevant to the social and physical environment. In this regard, Government efforts will be directed at:

Strengthening community-based health care programmes, and promoting mobile outreach clinics for remote areas;

Ensuring that drugs and equipment meant for health facilities reach the intended destinations;

Intensifying immunization of vulnerable children and other members of the pastoralist community and strengthening district capacity to detect and contain epidemics; and

Providing public health education to communities for preventive and promotive health care.

1.6 NHSSP II - Key principles of AOP2

In keeping with the five broad policy objectives of the second National Health Sector Strategic Plan for 2005–2010, AOP 2 was developed with four main principles as guides. These are:

Norms and standards for the various service delivery levels guided the development of the implementation plan in the area of human resources, infrastructure and commodities.

The move towards SWAp helped to strengthen synergies among the various stakeholders contributing to the realization of the health targets. For the first, time the outputs of major FBOs/NGOs in the health sector have been included in the annual operational plan.

The results-based management system introduced in AOP 1 highlighted the need to define specified outputs for the various levels of health care to ensure that performance can be monitored during implementation.

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1.7 Strategic issues and policies of the ministry

1.7.1 Flow of funds to rural health facilitiesThe Government introduced the District Focus for Rural Development Strategy in 1984, to act as a catalyst for harnessing and mobilising resources for maximum utilisation in the development of the rural areas where 80 percent of population lives. Under this Strategy accounting services were centralised within the District Treasuries to enable them serve all the Authority to Incur Expenditure holders. The District Treasury also became responsible for financial management of all Government funds in the districts.

The Strategy though a noble one, faced various challenges including:

Inadequate cash liquidity at District Treasuries to support district activities;

Inadequate participation of communities and lower level administrative structures in the planning processes;

Lack of systems to ensure funds flow to the spending units.

Although Treasury has taken several measures to eliminate these challenges, more reforms are required to ensure that funds flow to the spending units, are utilised for intended purposes and communities get value for the money. The 2005 public Expenditures Tracking Survey shows that 45% of funds and commodities earmarked for rural health facilities do not reach these units.

The inability of the rural health facilities to access funds on time has hindered their operations and almost brought to a stand still the implementation of public health activities. This, among others factors, may be the cause of deterioration of health status in the districts.

The Government has increased the allocations to the health sector to 8.4% of the total Government expenditure and this is expected to increase to 9.6% by 2008/9. These additional resources are intended to upgrade health infrastructure, procure medical commodities and support implementation of community strategy in line with the Ministry’s Second National Health Sector Strategic Plan (2005-2010).

The implementation of the community strategy and focusing attention to the lower level facilities will require modification of the financing

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arrangements for faster resource flow. However any modification must be within the existing Government financial regulations and procedures.

Given that the Ministry is looking forward to a Sector Wide approach (SWAp), as a coordination framework for the provision of health care services in the country, the flow of resources to health facilities and accountability is critical in achieving objectives and vision of the Second National Health Sector Strategic Plan.

The rural health facilities provide the frontline avenue in the delivery of health services in the country. There is need to ensure that financial resources are availed to make these services effective.

The MoH has, therefore, developed a Paper therefore that defines the Ministry’s position of disbursing funds to health facilities with an aim to create a robust financial system to facilitate:

Timely disbursement of funds, Production of timely financial returns; and Timely and accurate accounting for resources in the sector.

The Paper highlights crucial areas like: risk management, facility management structures, minimum staff requirements, resource allocation criteria, and mechanisms of the flow and accountability of funds, and lastly, monitoring and evaluation.

1.7.2 Guidelines to financial flow to health centres and dispensaries

In order to facilitate the implementation of the Position Paper on the flow of funds to the health centres and dispensaries, comprehensive Guidelines have been developed, in recognition of the importance of empowering the rural health facilities management to make decisions on the use of the resources made available to them.

As expected, the local community will enjoy good access to services, with ultimate improvement in health status. The Guidelines aim at contributing to the strengthening of rural health management capacity, with emphasis on financial management.

The starting point in service delivery is to prepare work plans. The facility work plan shows how services are organized as well as how resources (such as finances and personnel) are combined to render the service.

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Important components covered by the Guidelines include: resource management, planning health facility activities, operating financial management systems, procurement of goods and services, and documentation of accounting records.

Emphasise is given of the development of work plans and approved by the management committees as a starting point in financial management. It will be on the basis of the plans that financial resources will be released to the facilities.

1.7.3 Procurement position paper

The Government is committed to the attainment of the millennium development goals (MDG) as well as the targets set in the Economic Recovery Strategy for Employment and Wealth Creation (ERSWC). Revitalising the health sector in order to improve service delivery and ensure community participation as well as enhancing cooperation with all stakeholders in the sector is therefore being undertaken.

A five-year Second National Health Sector Strategic Plan 2005-10 whose goal is to reserve trends in health outcomes has been developed with an orientation on output and performance. This is in line with the Government reforms that are intended to institutionalise results based management approach in the public service. The ministry has initiated processes aimed at implementing the Plan through the Sector Wide Approach (SWAp).

The position paper which outlines procurement improvement plan is part of the preparation of the four year Joint Programme of Work and Funding, 2006-2010, and provides critical analysis of the procurement capacities, competences as well roles and functions of the procurement entities of the various levels within the Ministry of Health. Public procurement is broadly defined as the purchasing, hiring or obtaining by any other contractual means of goods, construction works and services by the public sector.

The importance of government procurement from a development perspective is self-evident, as the purchase of goods and services accounts for KSh 8 billion (30% of MOH allocation) The need to enhance transparency in public procurement cannot be over-emphasized within the framework of the Programme of Work.

This position paper addresses the following issues and proposes the possible interventions in order to facilitate a more efficient and effective procurement function in the public health sector.

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Some of the key issues addressed are:

a) Procurement responsibilities for goods, works and services at the different levels.

b) To institutional arrangements for decentralization of procurement responsibilities at the various levels in the health sector.

c) The special considerations for procurement of essential medicines and medical supplies;

d) The suitable arrangements for procurement of works in the health sector;

e) Recommendations on procurement capacity requirements with respect to:

Staffing and skills; Tools and procedures.

The development of the procurement position paper was based on four key pillars in the procurement system. These are:

Transparency Accountability Value for money Efficiency

The Paper highlights the procurement responsibilities at the various levels (KEMSA, MOH Headquarters, various KEPH levels), institutional arrangement for procurement like tender committees and procurement committees, procurement capacity requirements, monitoring and evaluation.

1.8 MoH Collaboration with the Faith based organisations

Faith Based Organizations (FBOs) continue to be major player in health care delivery in Kenya. Most of them are found in remote parts where people are poor and cannot afford to pay for health care services when sick. In the 1980s, the Government used to set aside funds, which used to be disbursed to FBOs as grants.

The decline was a result of funding constraints in the Ministry of Health as a result of improved staff emoluments, increased number of health facilities supported by MOH and overall government budgetary allocation constraints to MOH (9.4% of GOK allocation to health as

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compared to the Abuja’s target of 15%). The support to FBO was subsequently discontinued in mid 1990s.

To date, institutions namely, Kenya Episcopal Conference Catholic Secretariat (KEC-CS) and Christian Health Association of Kenya (CHAK) coordinate the bulk of not-for-profit non-government health providers. Table 1.1 shows the distribution of facilities under the Government and FBOs.

Table 1.1: Health facilities by ownership, 2006Facility type Governme

nt KEC-CS

CHAK

CHAK/KCS

Hospital 147 44 24 68 Health centres

460 92 47 139

Dispensaries 1,630 281 311 592 TOTAL 2,237 417 382 799

Despite the cessation of funding, the government has continued to deploy some personnel to mission hospitals as well as some assistance with drugs, medical supplies and equipment and vehicles but on an ad hoc basis.

Main source of support for the FBOs is currently the user fees which have contributes over 80% of recurrent expenditure. This source, however, is threatened due to decline in donor support to FBOs. Improvement of health care services in public health facilities as resulted in influx of patients to them; this in turn as resulted in reduced utilisation in FBOs facilities and hence reduced revenues. According to a MoH study4 focusing on facility utilisation after the introduction of 10/20 policy on July 1st 2004, which set a standard fee of KSh 10 at the dispensary, level and KSh 20 at health centres, utilisation of services in the sample facilities generally increased rapidly following the introduction of the policy. However, this growth was not sustained. In the last quarter of 2004 many facilities generally experienced declining utilisation although the picture varies by district and according to the type of service and utilisation remains, on the whole, above levels in

4 Ministry Of Health: RHF Unit Cost/Cost Sharing Review Study & The Impact Of The 10:20 Policy, 2005.

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the first quarter of 2004. In the first half of 2005 utilisation of services at health centres appears to have increased and is now roughly back at the levels experienced in July 2004. Utilisation in dispensaries has seen a slight decline in 2005 although, again, it remains above levels before 10/20 was introduced. This may have led to the subsequent decline in utilisation of FBO facilities and hence decline in their users fees revenue collection.

1.8.1 Current collaboration with FBOs

In the context of the Public Service Sector Reforms in general and the Sector Wide Approach (SWAp) in particular, the Faith Based Organisation (FBOs) have effectively participated in the development of the National Health Sector Strategic Plan II (NHSSP II 2005-2010). The FBOs form an important strategic partner in the implementation of the Plan of which collaboration is a key element in its success.

There is need, however, to strengthen partnership and collaboration between Ministry of Health and the Faith Based Health Services on a long-term basis.In this regard, a technical Working Group (MOH/FBHS - TWG) comprising MOH, CHAK, KEC, MEDS, and SUPKEM has been put into place. The Minister for Health and Church leaders have approved the terms of reference (TOR) for the Team. The TOR comprise 2 major categories:

a) Situation analysis study of FBHS vis-à-vis Health sector Services in Kenya including assessment of Human Resources situation and the various financing options

b) Development of a draft partnership policy document guided by SWAp spirit

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1.8.2 Progress report on MOH/FBHS - TWG on partnership policy Development

a) The Group has been meeting regularly and discussing among other issues, the Human Resources Crisis affecting the faith based facilities after recent recruitment of staff by the Ministry of Health.

b) The Group was granted Technical Assistance by development partners for the situation analysis study and has scheduled a 2-day retreat to meet with the consultants to discuss and develop data collection instruments for the study.

The situation analysis study outcome will inform the development of the draft partnership policy document to give guidance in the long-term collaboration and partnership.

Current Levels of Support to FBO

The Kenya Episcopal Conference (KEC) and Christian Health Association of Kenya (CHAK) met His Excellency the President Hon. Mwai Kibaki on 12th September 2006 to discuss the crisis facing the Faith Based Organizations Health Care Services in Kenya. His Excellency the President directed that Faith Based Organizations discuss with the Ministry of Health on the level and modalities of support and present their report in a month’s time.

In response, four technical committees were set up to deliberate and come up with amicable solutions. The outcomes of these committees were as follow:

1.8.3 Immediate re-instatement of financial grant to church Health facilities

The Ministry is not able to reinstate the grants to FBOs in 2006/7 financial year, because of current freeze on increment of grants. However, the Ministry has and will continue to support the FBOs in-kind. For example, the total support to FBOs this year in form of drugs and seconded personnel is expected to be KSh 297 million or 1.4% of the Ministry’s recurrent budget. The Ministry will integrate the grant to the FBOs in the MTEF and raise the same to a minimum of 2.8% of the recurrent budget in 2007/8. This grant will be provided in form of

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drugs, non-pharmaceuticals, personnel, equipments and cash to support operations and maintenance of health facilities.

Human Resource for Health issues

The biggest challenge, facing the FBOs is shortage of staff. Currently the FBOs require an additional of 6,241 personnel across all medical cadres to close the deficit. To close this deficit, KSh 854 million is required. The situation has been made worse by the fact that the FBOS are having difficulty in paying their workers enhanced salaries to match those offered by the Civil service The Ministry recognizes that the Faith based Organizations are key partners in health service delivery and its collapse will have negative impact on the health sector. In order to support the FBOs, the Ministry has seconded 51 doctors and 44 nurses.

The Ministry will second 309 nurses to FBO health facilities this year. This will increase the total support to FBOs in form of personnel to KSh 136 million in 2006/7. The FBOs on their part will use the savings derived from this support to employ additional staff or top-up salaries for their staff to be comparable to those in the Civil Service.

Other issues being considered

These include the exemption of taxes, licenses and levies

1.8.4 Support in kind through Drugs, Medical Supplies Equipment and Ambulances

The Ministry will continue to provide to FBOs support with vaccines, family planning commodities, HIV Test kits, ARV drugs, anti-TB drugs and diagnostic supplies and anti-malarial drugs and ITNs.

The current ad hoc arrangement where individual FBO facilities are receiving medical supplies from KEMSA worth KSh 166 million will be discontinued with immediate effect and future support channelled through FBO Secretariats.

Twenty ambulances will be earmarked for FBOs in 2006/07 to be distributed to institutions of their choice.

1.8.5 Legal Policy Framework

The process is on to develop and recommend partnership framework to be ready by the end of the 2006 with the aim to:

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Harmonize FBOs activities in the health sector to reduce competition and duplication;

Prioritise facilities in deserving or underserved areas to receive full support from the Government;

1.8.6 Donor support to the Health Sector

The MOH in collaboration with Development and Implementing Partners is developing Sector Wide Approach Strategy (SWAps) that will ensure better harmonization and coordination of planning, implementation and monitoring of activities in the Health Sector. The FBO health facilities, as key implementing partners, will have their Annual Plans and needs included in the Health Sector Annual Operational Plans (AOPs) and supported through the SWAps financing arrangement.

1.9 The Scope and Organization of this Public Expenditure Review

This Public Expenditure Review (PER) introduces and then discusses the major dimensions of public financing and expenditure of the health sector in Kenya. It will serve to provide accurate public health spending data for Kenya.

In addition to its incorporation of the findings and data of previous PER (2006), this PER provides an update on the public health spending for the five-year period 2001/02 through 2005/06, and analyses several of the important policy issues that are raised and highlighted in these data.

This PER concludes by offering some recommendations. Data presented here were gathered and processed by the Central Planning & Monitoring Unit (CP&MU) team in collaboration with Accounts and Finance divisions.

This report is divided into twelve parts. Following this Chapter One, which gives relevant background information on Kenya’s health sector, Chapter Two displays and discusses, in summary and in detail, public spending on health during the five-year period 2001/02 through

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2005/06. Chapter Three addresses particular issues in review of core poverty/programmes,Chapter Four addresses issues of on-going and stalled projects, chapter Five deals with issues of resource requirement 2007/08-2009/010, Chapter Six analysis the ministry’s out-put and related indicators,Chapter Seven deals with issues of Pending Bills,Chapter Eight deals with public expenditure management (PEM), Chapter Nine deals with issues of human resource development and capacity building, Chapter Ten addresses the implementation of 2006 PER, Chapter Elveen gives the conclusions and recommendations while chapter Twelve concludes with findings and recommendations that derive from the foregoing analyses of the data presented and the policy issues raised and discussed.

1.10 The Ministry’s Mission Statement and Core activities

The vision of MoH as envisaged by the Kenya Health Policy Framework for 1994–2010 is an efficient and high quality health care system that is accessible, equitable and affordable for every Kenyan, which remains appropriate as a guide for NHSSP II.

The MoH mission is to promote and participate in the provision of integrated and high quality promotive, preventive, curative and rehabilitative health care services to all Kenyans. Linking to the ERS and MDGs, the mission of the MoH translates into the following set of policy objectives:

Increase equitable access to health services. Improve the quality and responsiveness of services in the sector. Improve the efficiency and effectiveness of service delivery. Enhance the regulatory capacity of MOH. Foster partnerships in improving health and delivering services. Improve the financing of the health sector.

There are a number of parastatals in the Ministry, namely Kenya Medical Research Institute (KEMRI), Kenya Medical Training College (KMTC), Kenyatta National Hospital (KNH), Moi Teaching and Referral Hospital, Kenya Medical Supplies Agency (KEMSA), and the National Hospital Insurance Fund (NHIF). These parastatals complement the services provided by health centres, dispensaries and district and provincial hospitals.

1.10.1 Kenyatta National Hospital

Kenyatta National Hospital through its mandate as provided for in the Legal notice No. 109 of 1987 has the core functions of providing

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specialised quality health care; facilitation of training and research and participation in national health planning and policy. The hospital has the vision to be a regional centre of excellence in the provision of innovative and specialized health care. The hospital has developed a strategic plan to guide it through 2005 to 2010.

Staffing: The hospital has staff strength of nearly 4,700 against an approved establishment of 6,200. This has resulted in understaffing of certain critical areas, such as the nursing department where the patient to nurse ratio is way below the WHO recommended ratio of 1:6. The Plan recognises that it is the staff that will ultimately make the plan a reality. The Plan’s strategic interventions are expected to achieve the following:

Well motivated and committed employees; More skilled staff; Right staff for the job; Competitive advantage; Increased revenue; and Overall improved health care delivery.

The increased revenue collection will, no doubt, have important implications for the MoH budget. Currently, 12.2% of total MoH budget (13.2% of recurrent and 10.2% of development) is allocated to KNH. The development allocations are a one time support to KNH to support upgrading of equipments. The Poverty Reduction Strategy Paper (PRSP) proposes reduction of the budget allocation for Kenyatta National Hospital, as a share of the total MOH recurrent budget to 10%.

Although efforts have been made to reduce allocations to KNH, the current award of salaries to unionisable staff (over Ksh 386 million is required to implement the award) may reverse the gains made so far.

Workload: There has been a steady in the inpatient and outpatient workload in the hospital (figure 1.1) resulting in increased pressure on physical, financial and human resources. However, it is apparent that the figures are falling probably as a result of decongestion of the hospital after operationalisation of the Nairobi City Council health facilities through secondment of staff by the MoH.

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1.10.1.1 Financing

As seen in Table 1.1, the GoK funding has been below the projected budgetary requirements of the hospital, resulting in non-availability of development funds and inadequate financing of the recurrent expenditure. In 2005/06, out of the KSh 2.9 billion grant from MoH, KSh 2.5 billion was utilised on personnel emoluments while the remaining KSh 0.40 million was used for development and operations and maintenance.

The total budget for KNH (including cost sharing) was about 24% of the Ministry of Health Recurrent budget in 2005/6. Table: 1.1 KNH proposed budget and Actual allocations

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FY Proposed Budget

Actual Allocations (MOH)

Cost Sharing Collections

Total Allocations+ CSF

1999/00 2,075.2 1,359.1 404.5 1,763.72000/01 1,754.2 1,349.6 534.8 1,884.52001/02 5,283.9 1,865.2 807.1 2,672.42002/03 5,289.7 2,327.0 596.5 2,923.5

2003/04 5,788.0 2,448.0 952.43,400.4

2004/05 9,733.42,659.0

917.2 3,576.22005/06

6,358.0 2,858.01,852.1 4,710.1

Source: KNH- Strategic Plan 2005- 2010

As can be seen from the above table the revenue collections at the hospital doubled from Ksh 917 million in 2004/5 with the initiation of computerizations of the collections process. The increased revenue and prudent management enabled the hospital to return a surplus of Ksh 423 million.

The impact of this inadequate funding has led, among others to:

Inefficiency in provision of diagnostic services

Prolonged length of stay of patients, for example, in the orthopaedic wards as the hospital is unable to procure required items, thus leading to congestion;

Inability to replace, rehabilitate medical equipment;

Backlog of patients requiring open-heart surgery operations.

1.10.1.2 Impact of Poverty on the hospital

The high poverty levels in the country have serious implications on KNH, as majority of patients visiting the hospital are unable to pay for services received. This has threatens hospitals efforts of being self-sustaining, thereby reducing its dependency on the exchequer.

Table 2.0: Waivers and exemptions 1999/00- 2003/04Year Amount

(KSh million)1999/00 128.4

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2000/01 146.12001/02 130.52002/03 180.12003/04 98.5Total 683.6Source: KNH- Strategic Plan 2005- 2010Insert figures for 2006/07 As a result of streamlining the waiver issuance process, the levels of waivers heave gone down to 5.2% of the cost sharing revenue in 2003/4.

1.10.1.3 Restructuring Programme

The hospital management has developed a restructuring programme to streamline hospital operations. This will include staff rationalisation, computerisation of hospital operations and out-sourcing of non core activities.

1.10.2 Kenya Medical Research Institute (KEMRI)

The vision of KEMRI is to be a leading centre of excellence in the promotion of quality health, which will be achieved through research. KEMRI has developed a Strategic Master Plan which also seeks to contribute to the realisation of the MDGs. The Plan also ties with the NHSSP II 2005-2010 whose theme is to reverse the downward trends in Kenya’s national health scene. The new Kenya Essential Package for Health (KEPH), under the Plan puts emphasis on health (rather than disease), on rights (rather than needs) and on revitalisation of health particularly at community level. This ties up well with the KEMRI Strategic Master Plan whose view is to improve not just health but quality of human life.

Financial Resource: KEMRI has in 2005, an annual budget of KSh 3 billion. The Government of Kenya provided 50% of the budget while collaborating research partners and organisations provided 45%. The remaining 5% is raised from the Institute’s own internal sources.

1.10.2.1 AchievementsSome of the key achievements that have a bearing on the improvement of health status in Kenya as well as contributing to the core activities of the MoH include:

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Through the Institute‘s advice to the MoH on rational use of drugs, the malaria drug Daraprim was withdrawn from the market. Chloroquine was withdrawn as a first line drug in the treatment of malaria.

The development of national disease surveillance and rapid response capacity for major disease outbreaks. It is this capacity that has enabled the nation to respond quickly and effectively to yellow fever, rift valley fever and viral haemorrhagic fever outbreaks in Kenya. It is also this capacity that keeps outbreaks, including those for catastrophic diseases such as the Ebola, Marburg, SARS and others away from Kenya.

Development of Insecticide Treated Bed nets (ITN s) for use in the control of malaria.

Development of treatment regimens that have reduced the treatment period for leprosy from 18 months to 1 month (which has almost eliminated leprosy in Kenya); tuberculosis (TB) from 18 months to 3 months and leishmaniasis (Kalazar) from 30 days to 10 days.

Unique contributions in health research technology which includes the development of the KEMRI Hepcell kit for diagnosis of infectious hepatitis, the Particle Agglutination (PA) kit for the diagnosis of HIV and the HLA tissue typing techniques for kidney transplants.

Development of various formulations for treatment of HIV/AIDS and opportunistic infections. KEMRI has also developed a comprehensive training module for HIV/AIDS education awareness at the workplace towards strengthening of HIV/AIDS information, education and communication control initiatives.

KEMRI is a World Health Organization (WHO) collaborating centre for HIV/AIDS, polio immunization, viral haemorrhagic fevers, leishmaniasis, leprosy and antimicrobial resistance.

1.10.3 National Health Insurance Fund

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NHIF was established through an act of parliament in 1966 with the main objective of financing health care in Kenya. Membership to NHIF is compulsory with a monthly salary of KSHS. 1,000. The current act provides for outpatient and inpatient benefits to members. However, the fund provides inpatient benefits to members only. In line with the Health Sector Strategic Plan II and the ERS objective of improving access to health care, the Government intends to transform NHIF into a social health insurance. In pursuant to the above objective of improving access to health care, NHIF has also enhanced the benefit package to members by establishing a comprehensive inpatient package by extending coverage to include consultation and diagnostic.

1.10.3.1 Contributions and benefit payment

Over the years, revenue collection by NHIF has continued to increase. Revenue from contribution from members increased from Kshs. 2.5 billion in fiscal year (FY) 2002/03 to over Kshs. 3.5 billion in FY 2005/06. This can be attributed to mechanisms put in place by NHIF to enhance revenue collection that include enrollment of new members both from the formal and informal sector. During FY 2005/06, NHIF registered a total of 181,583 new members with 10,543 coming from the informal sector. Reimbursement to accredited hospitals also increased from Kshs. 820,000 in FY 2002/03to Kshs. 1.1 billion in FY 2005/06. However, in FY 2003/04 and 2004/05, the reimbursements were on a downward trend due to better claim management through decentralization of operations. The significant increase in reimbursement in FY 2005/06 was attributed to the enhanced rebates to contributors. However, as a percentage of total revenue, reimbursements decreased from 30% in FY 2002/03 to 21% in FY 2004/05. It then increased to 30% in FY 2005/06.

The administration5 component of the expenditure recorded a minimal decline over the period under review decreasing from Kshs. 1.62 billion in FY 2002/03 to Kshs. 1.53 billion in FY 2005/06. The administration component has been consuming a significant portion of the total revenues. The administrative component as a percentage of the total revenue recorded a downward trend, dropping from 59% of the total revenues in FY 2002/03 to 42% of the total revenues in FY 2005/06. However, this is still way above the international recommended level for health insurance-10%—12%.

5 Includes personnel and other admin expenses

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Table: Growth of members’ contributions and reimbursements2002/03 2003/04 2004/05 2005/06

REVENUESContributio

ns2,523,876,081

2,639,883,578

3,117,241,202

3,458,847,816

Other income6

210,992,974

72,358,041

157,349,232

188,463,585

TOTAL REVENUES

2,734,869,055

2,712,241,619

3,274,590,433

3,647,311,401

EXPENDITUREReimburse

ments822,014,878

713,297,431

685,490,051

1,105,875,734

Administration

1. Personnel

776,263,163

827,258,377

1,040,765,820

1,030,516,535

2. Other admin

846,506,931

704,478,176

538,018,321

496,191,147

Total admin expenses

1,622,770,094

1,531,736,553

1,578,784,141

1,526,707,682

TOTAL EXPENDITURE

2,444,828,033

2,245,033,984

2,264,274,192

2,632,583,416

Reimbursements as % of total revenue

30 26 21 30

Total admin as a % of total revenue

59.34 56.47 48.21 41.86

Other medical benefitsIn line with the funds mandate of enhancing access to health care, NHIF donated 80 Ambulances to GoK hospitals to facilitate transportation of patients from rural health facilities to hospitals where specialized care is required. The fund has also in recent past held several free medical camps in remote areas where access to health care is a major problem.

6 Incomes accrued from short and long term investments

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Recommendation In line with the NHSSP II, the funds obligation is to raise benefits to members. In addition, NHIF should strife to reduce administrative costs to 10-12% of the contributions and therefore be in line with acceptable international standard.In addition, NHIF should utilize surplus to pay for additional benefits.

1.10.4 Kenya Medical Training College (KMTC)

The KMTC, established in 1990, has the following core responsibilities:

Provide facilities, in addition to those of Universities other colleges, and schools, for college education for health manpower personnel training.

Facilitate the development and expansion of opportunities for Kenyans for continuing education in various disciplines of medical training.

Provide consultancy and technical advice in health related training and research.

Develop health trainers with the capacity to conduct research, develop usable and relevant health learning materials, and manage health-related training institutions.

Provide guidance and leadership for the establishment of constituent training centres and facilities.

Since its inception, KMTC has managed to establish a number of constituent colleges in a number of district hospitals. These colleges have managed to train a large number of students, many of whom are currently providing services in different institutions in the country. KMTC relies on the government for up to 80% (or Ksh 593 million) of the funding, with the rest generated from student fees, investments, and grants.

The proposed harmonisation exercise to equalise salaries and allowances payable to KMTC staff to those in the Civil service will put pressure on personnel allocations to the institution. A total of Ksh 90.8 will be required for the harmonisation exercise.

1.10.5 Kenya Medical Supplies Agency (KEMSA)

In 2005, the Health Ministry took a significant strategic leap forward by transforming the Kenya Medical Supplies Agency (KEMSA) from a medical store to a semi-autonomous government agency to provide medical logistics to public health facilities countrywide.

/23

KEMSA is mandated to:

Develop and operate a viable commercial service for the procurement and sale of high quality drugs and other medical supplies;

Provide a secure source of drugs and other medical supplies to public health institutions; and

Advise the Health Management Boards and the general public on matters relating to the procurement, cost effectiveness and rational use of drugs and other medical supplies.

The National Health Sector Strategic Plan envisioned KEMSA to be “a secure source of essential medicines for all public health facilities”, one of the four key pillars in reducing disease burden and move closer to achieving one of the millennium development goals—to reduce child and maternal morbidity. The other pillars are rational drug use, affordable cost/price and sustainable financing for drugs.

Procurement of drugs is based on the 2003 edition of the Essential Drug List. The volume of commodities to be procured is determined by a quantification exercise that is compiled annually by the program managers of MoH in collaboration with KEMSA and the Chief Pharmacist of Ministry of Health.

In 2004/5 and 2005/6, KEMSA was enabled to procure the rural health facility kits and hospital pharmaceutical worth Ksh 1.1 billion and Ksh 1.5 billion respectively. it is expected that in 2006/7, all drugs and non-pharmaceuticals will be undertaken by KEMSA in line with the Ministry’s position paper on procurement.

Distribution: KEMSA Logistics function aims to deliver medical supplies direct to all health facilities in Kenya consistently and efficiently. In partnership with experienced third party transport service providers, KEMSA has set up a distribution structure with the capacity to reach all public Hospitals, Rural Health Centres and Dispensaries throughout the country.

By making timely deliveries against hospital orders with regular deliveries to rural health facilities based on a mutually agreed schedule, KEMSA Logistics will remain versatile and responsive to public customer requirements

A process has started aimed at integrating parallel programmes such as Reproductive Health commodities, TB/Leprosy and ARV’s into KEMSA’s overall distribution process. Ultimately, this will cut down on

/24

distribution costs and ensure medical commodities are managed within one supply chain resulting in greater reach and efficiencies whilst utilizing limited available resources.

The biggest challenge facing KEMSA is lack of funds for capitalisation and for distribution. Discussions are on-going to use the current stocks to capitalise KEMSA and pay for the medical supplies based on delivery. An allocation to cater for distribution will also be made available in 2006/7.

1.10.6 Moi Teaching and Referral Hospital

Moi Teaching and Referral Hospital (MTRH) is the second national referral hospital in Kenya after Kenyatta National Hospital (KNH). It was started in 1917 as a cottage hospital with bed capacity of 60, it has grown tremendously to a national referral hospital with a capacity of nearly 500 beds.

The teaching and referral facility status was accorded by Legal Notice No. 78 of 12 June 1998 under the State Corporations Act (Cap 446) and the first Board of Management was gazetted on 29 June 1999. A three-year business plan prepared by the Hospital Board of Management immediately after its inception became the first document upon which the board based its actions.

The plan articulated the vision and mission of the hospital and set out the organizational structure. It remains to-date the only authentic document guiding major policies on financial management and control, recruitment, and hospital capitalization. However, due to the many challenges posed by rapid developments in the hospital, a Strategic Plan for 2005–2010 has been developed. The hospital is mandated to carry out the following functions:

Receive patients on referral from other hospitals and institutions within and outside the country for specialized health care;

Provide facilities for medical education for Moi University, and for research in collaboration with other health institutions;

Provide facilities for education and training in nursing and other health and allied professions;

Serve as a national referral hospital in national health planning. It consumes 3.6 % 0f the total MOH recurrent expenditure

The 2005/6 allocations to the hospital amounted to Ksh 714 million or 3.6% of the Ministry’s recurrent budget. The hospital will require an

/25

additional Ksh 131 million for salary and allowances harmonisation exercise.

1.10.7 Increasing AccessImproving access – geographically, financially and socio culturally – generally facilitates increase in the utilization of health care services, as the services become closer and cheaper for the client. This in turn may result in improved health status of the population.

In order to improve on physical assess, during the financial year 2006/07, the MoH will (has been) gazette (d), some 600 health facilities, mainly dispensaries that have been constructed using the constituency development fund (CDF). Of these, 300 will be taken over by the ministry and become functional.

2 Government Spending on Health through the MoH

2.1 Public Spending on Health: Context

Table 2.1 presents as an introduction to a detailed discussion of the trends in Kenya’s public health spending, health economic data for selected countries in the Eastern and Southern African region. Kenya ranks third on per capita public spending and spends 7.2% of total Government spending on health, but this is expected to increase with the recent increase in investment in the health sector.

Table 2.1: Total Public Spending on Health - Selected East and Central African Countries, 2005

CountryAs a % of GDP

As % of Total Govt

Per Capital (US$)

Kenya 2.2 7.2 8Tanzania 2.7 12.7 7Uganda 2.1 10.7 5Zambia 3.1 11.8 11Malawi 4.0 9.1 5Zimbabwe 4.4 9.2 14Rwanda 3.1 7.2 3Burundi 0.6 2.0 1Ethiopia 2.6 9.6 3

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Source: UNDP: Human Development Report 2005 WHO: The World Health Report, 2006

2.2 Government Spending on Health: Aggregate Levels and Trends

2.2.1 Total Spending on HealthTotal government spending on health has risen substantially during the five-year period 2001/02 through 2005/06, increasing from KSh 15.2 billion in 2001/02 to KSh 23 billion in 2005/06 (see Table 2.2). The expenditure growth was uneven. But there is evidence of increasing rate over the previous year occurring since 2003/04- a 7.1% increase in 2003/04, a 16.5% increase in 2004/05, and a 20.1% increase in 2005/06 for combined recurrent and development.Table 2.2: Ministry of Health Actual Expenditure (Gross) KSh million 2001/

022002/03

2003/04

2004/05

2005/06

Recurrent 12,715

14,405

15,438

17,417

19,765

Development 2,519 945 1,003 1,741 3,242

Total15,234

15,351

16,441

19,158

23,007

Increase (Recurrent) over previous year (%)15.2 13.3 7.2 12.8 13.5Increase (Recurrent + development) over previous year (%) 26.2 0.8 7.1 16.5 20.1

Per Capita KSh488.44

481.97

506.05

578.28 681.78

Per Capita $ 6.28 6.29 6.52 7.48 9.47Ministry of Health Expenditure

(Gross) as % of Total Government1

Recurrent 8.23 8.69 7.76 7.66 6.29 Development 17.18 5.12 2.77 2.01 3.73 Total 9.01 8.33 6.99 6.1 5.73Ministry of Health Expenditure

(Gross) as % of GDP Recurrent 1.38 1.4 1.41 1.41 1.29 Development 0.27 0.09 0.09 0.14 0.21 Total 1.65 1.49 1.51 1.55 1.50

However, these impressive nominal increases in public health spending in 2001/02, in 2003/04, and in 2005/06 did not constitute significant relative changes in resource allocation to health when compared to two important benchmarks - gross domestic product (GDP) and total

/27

government spending (in all sectors) - because both grew at similar rates.

As a percent of total government recurrent expenditure, therefore, public heath recurrent spending declined slightly over the period, being 8.23% in 2001/02 and 6.29% in 2005/06—even though it rose briefly to 8.69 % in 2002/03. On the other hand, as a percent of GDP, total government health spending rose slightly over the same period, being 1.65 % of GDP in 2001/02 and 1.55 % in 2004/05 of GDP and 1.50% in 2005/06.

2.2.2 Recurrent and Development Expenditure

For the period 2001/02 through 2005/06 period, more than half ( ½) (52.7%) of the MoH’s expenditure was on personnel emoluments, 7.5% spent on operations and maintenance and, just about 3% spent on purchases of plants and equipment (see Table 2.3). About 10.5% was spent on drugs and medical supplies and about 26.4% on “transfers” to MOH parastatals.

2.2.2.1 Ministry of Health Recurrent Expenditure by Economic Category

Table 2.3 Recurrent (gross) Expenditure by Economic Category KSh millions

2000/01 2001/02 2002/03 2003/04 2004/05 2005/06

Actual Actual Actual Actual Actual Actual Total Recurrent (Gross) 11,040.8 12,714.9 14,405.4 15,438.5 17,417.4 19,765.1Salaries and Other Personnel 5,251.8 6,639.9 7,798.1 8,100.8 9,034.9 10,407.3 as % Total Recurrent 47.6 52.2 54.1 52.5

51.9 52.7

Transfers, Subsidies and Grants 848.1 1,027.7 1,157.2 1,454.7 1,562.5 1,634.9 as % Total Recurrent 7.7 8.1 8.0 9.4

9.0 8.3

Drugs and Medical Consumables 1,680.8 1,476.8 1,349.7 1,716.0 1,866.2 2,074.2 as % Total Recurrent 15.2 11.6 9.4 11.1

10.7 10.5

Other Operations & Maintenance 1,749.9 1,324.0 1,257.4 1,285.2 1,756.0 1,481.0 as % Total Recurrent 15.8 10.4 8.7 8.3

10.1 7.5

Purchase of Plant & Equipment 160.6 29.0 94.5 14.6 80.7 595.6 as % Total Recurrent 1.5 0.2 0.7 0.1

0.5 3.0

Kenyatta National 1,349.6 1,865.2 2,327.0 2,409.0 2,659.0 2,858.0

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Hospital as % Total Recurrent 12.2 14.7 16.2 15.6

15.3 14.5

Moi Referral Hospital 0.0 352.3 421.5 458.1 458.1 714.1 as % Total Recurrent 0.0 2.8 2.9 3.0 2.6 3.6

2.2.2.2 Ministry of Health Expenditure (Actual) by sub Vote

Table 2.4: Ministry of Health Recurrent Expenditures (gross) by Sub Vote KSh Millions

Sub-Vote 2000/200

1 2001/20022002/200

32003/2004 2004/05 2005/0

6

Actual Actual Actual Actual Actual Actual 11

0General Admin. And Planning 700.7 587.0 714.8 760.4

1,223.0

912.527

Total as % Total MoH 6.3 4.6 5.0 4.9 7.

0

4.6 11

1Curative Health 6,080.9 6,758.6 7,677.6 7,768.0 8,639

.5 9996.7

59


6

50.6 11

2Preventive and Promotive 874.4 665.2 632.2 863.6

795.9

756.995


6

3.8 11

3Rural Health Services 1,121.4 1,378.1 1,436.4 1,687.6 2,041

.5 2881.6

56


7

14.6 11

4Health Training and Research 884.2 1,060.2 1,161.8 1,459.8

1,467.7

1511.916


4

7.6 11

6Medical Supplies Coord Unit 29.6 48.3 34.2 32.0

132.6

133.177


8

0.7 11

7Kenyatta National Hospital 1,349.6 1,865.2 2,327.0 2,409.0

2,659.0

2858.014


3

14.5 11

8Moi Teaching and Referral 0.0 352.3 421.5 458.1

458.1

714.072


6

3.6

Total MoH 11,040.8 12,714.9 14,405.4 15,438.5 17,417

.4

19,765.

1


0

100.0

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Table 2.5: Ministry of Health: Development Expenditures (gross) by Sub Vote KSh Millions.

Code Sub-Vote 2000/2001 2001/2002 2002/2003 2003/2004 2004/05 2005/06

Actual Actual Actual Actual Actual Actual

110General Admin. and Planning 16.9 1,193.2 432.5 196.9

158.7 357.213

Total as % Total MoH 1.6 47.4 45.8 19.6

9.1

11.0

111 Curative Health 98.0 637.2 120.1 206.5 162.

0 702.779 Total as % Total MoH 9.5 25.3 12.7 20.6

9.3

21.7

112Preventive and Promotive 386.2 134.0 183.4 87.9

934.0 1162.316


53.6

35.9

113Rural Health Services 248.8 397.7 198.4 446.1

466.2 913.5


26.8

28.2

114Health Training and Research 281.6 157.3 10.9 65.6

20.0 56


1.1

1.7

116

Medical Supplies Coord Unit 0.0 0.0 0.0 0.0 - 50 Total as % Total MoH 0.0 0.0 0.0 0.0

-

1.5

117

Kenyatta National Hospital 0.0 0.0 0.0 0.0 - 0 Total as % Total MoH 0.0 0.0 0.0 0.0

-

-

118Moi Teaching and Referral 0.0 0.0 0.0 0.0 - 0 Total as % Total MoH 0.0 0.0 0.0 0.0

-

-

Total MoH 1,031.5 2,519.4 945.3 1,003.0 1,74

1.0 3

,241.9 Total as % Total MoH 100.0 100.0 100.0 100.0

100.0

100.0

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Table 2.6: Ministry of Health Total Expenditures (gross) by Sub Vote KSh Millions

Code Sub-Vote 2000/2001 2001/2002 2002/2003 2003/2004

2004/05

2005/06

Actual Actual Actual Actual Actual Actual

110

General Admin. and Planning 717.6 1,780.2 1,147.3 957.3

1,38

1.7

1,26

9.7 Total as % Total MoH 5.9 11.7 7.5 5.8

7.2

5.5

111

Curative Health 6,178.9 7,395.8 7,797.7 7,974.5

8,80

1.6

10,699.5


45.9

46.5

112

Preventive and Promotive 1,260.6 799.2 815.6 951.5

1,73

0.0

1,91


9.0

8.3

113

Rural Health Services 1,370.2 1,775.8 1,634.8 2,133.7

2,50

7.7

3,79


13.1

16.5

114

Health Training and Research 1,165.8 1,217.5 1,172.7 1,525.4

1,48

7.7

1,56


7.8

6.8

116

Medical Supplies Coord Unit 29.6 48.3 34.2 32.0

132.

6

183.

2 Total as % Total MoH 0.2 0.3 0.2 0.2

0.7

0.8

117

Kenyatta National Hospital 1,349.6 1,865.2 2,327.0 2,409.0

2,65

9.0

2,85


13.9

12.4

118

Moi Teaching and Referral 0.0 352.3 421.5 458.1

458.

1

714.

1 Total as % Total MoH 0.0 2.3 2.7 2.8

2.4

3.1

Total MoH 12,072.3 15,234.3 15,350.7 16,441.5

19,15

8.3

23,007.0

Total as % Total MoH

100.0 100.0 100.0 100.0 100.

100.

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Table 2.6: Ministry of Health Total Expenditures (gross) by Sub Vote KSh Millions

Code Sub-Vote 2000/2001 2001/2002 2002/2003 2003/2004

2004/05

2005/06

Actual Actual Actual Actual Actual Actual 0 0

2.2.3 Budget Implementation Actual Expenditures versus Approved Budgets

Table 2.7 shows the comparison between approved and actual recurrent and development expenditures by sub vote. While the approved budgets may constitute the blueprint for spending, the actual expenditures reveal the true allocation and application of public resources.

In a few sub votes there is variance between actual expenditures with the approved budgets. In order to establish where these differences were significant, they were calculated and are presented in Table 2.7, which shows differences by sub vote.

It is seen that, while actual recurrent expenditures were either much below or much above the printed and approved budgets in the period 2001/20 to 2003/04, the gap tended to become narrower in 2004/05 indicating that financial management has improved.

A comparison between approved expenditure allocations across the main sub votes of expenditure and actual expenditures shows deviations ranging from 5% to 267%. The same significant variations were observed when printed estimated are compared with the actual expenditures. This is however in exception of the 2004/05 financial year.

/33

Table 2.7: Actual Expenditures Compared to Approved Annual Budgets for Expenditures on Health, Ministry of Health, and 2001/02 -2005/06.

Budget Implementation 2000/01 - 2005/062000/

012000/0

12001/

022001/0

22002/

032002/0

32003/

042003/0

42004/

052004/0

52005/

062005/0

6

Code Sub-Vote

Actual as % of Printed

Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved

Recurrent

110

General Admin. and Planning 193 137 141 135 137 132 157 141 135 97 88 84

111Curative Health 153 100 180 154 159 152 152 152 177 99 100 98

112

Preventive and Promotive 176 158 129 126 112 94 86 86 103 94 75 74

113

Rural Health Services 36 35 39 34 33 33 33 34 44 102 96 96

114

Health Training and Research 115 103 137 101 109 100 100 100 101 100 101 100

116

Medical Supplies Coord Unit 70 87 106 83 52 50 46 46 79 98 97 97

117

Kenyatta National Hospital 100 100 142 100 126 105 100 100 100 100 100 100

118

Moi Teaching and Referral 267 100 121 100 109 100 100 100 100 100

Total 111 105 121 100 106 100 96 97 109 99 98 96

Development

11General 11 23 158 95 50 43 25 32 27 57 35 51

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012000/0

12001/

022001/0

22002/

032002/0

32003/

042003/0

42004/

052004/0

52005/

062005/0

6

Code Sub-Vote


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved

0

Admin. and Planning

111Curative Health 11 22 75 107 14 23 26 60 23 38 46 41

112


113


114

Health Training and Research 92 99 100 5 5 21 46 2 7 10 9

116

Medical Supplies Coord Unit

117

Kenyatta National Hospital

118

Moi Teaching and Referral

Total 26 37 71 67 20 19 20 26 22 39 33 33Combined

110

General Admin. and Planning 140 123 152 105 82 74 76 83 92 90 62 71

111Curative Health 131 140 160 148 137 140 135 146 157 96 93 90

112


113


114

Health Training and Research 108 102 158 101 92 85 86 95 58 85 76 74

116

Medical Supplies Coord Unit 70 87 106 83 52 50 46 46 42 91 57 60

117

Kenyatta National Hospital 99 100 141 100 126 105 100 100 100 100 100 100

/35


012000/0

12001/

022001/0

22002/

032002/0

32003/

042003/0

42004/

052004/0

52005/

062005/0

6

Code Sub-Vote


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved


Actual as %

of Approved

118

Moi Teaching and Referral 267 100 121 100 109 100 100 100 100 100

Total 87 91 108 92 84 79 78 83 81 87 76 76

Table 2.8 shows the trends in actual spending as proportion of the printed and approved budgets by economic categories. There has been improvement for most of the categories, resulting in an improvement of actual expenditures nearly converging to 100% for both printed and approved budget.

/36

Table 2.8: Budget Implementation by economic category: 2001/02 - 2005/06

Economic Categories

2001/2002

2001/2002

2002/2003

2002/2003

2003/2004

2003/2004 2004/05

2004/05

2005/06

2005/06

Actual as %

of Printe

d

Actual as %

of Approved

Actual as % of Printe

d

Actual as % of Approv

ed

Actual as % of Printe

d

Actual as % of Approv

ed


Actual as %

of Approved


Actual as %

of Approved

Total Recurrent (Gross) 121 100 106 100 96 97

109

99 98

96.30

Salaries and Other Personnel 121 97 102 100 98 100

122

101 102

100.24

Transfers, Subsidies and Grants 135 98 108 100 100 100

98

98 100

99.69

/37

Drugs and Medical Consumables 87 99 93 92 80 80

94

94 83

90.17

Other Operations & Maintenance 121 120 108 98 102 95

99

99 90

74.09

Purchase of Plant & Equipment 85 80 99 98 73 74

95

95 86

94.52

Kenyatta National Hospital 142 100 126 105 100 100

100

100 100

100.00

Moi Referral Hospital 267 100 121 100 109 100

100

100 100

100.00

Table 2.9: Budget Implementation - Actual as % of Printed and Approved - Personnel emoluments by sub vote 2001/02 - 2005/06

Sub vote

2001/2002

2001/2002

2002/2003

2002/2003

2003/2004

2003/2004

2004/2005

2004/2005

2005/06 2005/06


Actual as % of Approve

d

Actual as % of

Printed

Actual as % of

Approved

Actual as % of

Printed

Actual as % of

Approved

Actual as % of

Printed

Actual as % of

Approved

Actual as %

of Printe

d

Actual as % of Approve

d

General Administration and Planning

148 146 165 154 164 171 217.3 103.3 88.4 85.6

Curative Health 209 169 179 170 171 172 208.6 100.0 106.1 103.6

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Preventive and Promotive 177 163 132 121 114 115 116.7 93.9 71.8 74.9

Rural Health Services 18 14 14 15 16 16 19.7 112.3 92.0 91.1

Health Training and Research 123 110 119 115 101 102 127.0 113.1 122.7 113.8

Medical Supplies Coordinating Unit 80 73 30 28 23 23 24.7 85.6 77.5 74.2

Total 121 97 102 100 98 100 122.1 100.8 102.3 100.2

Table 2.9.1 Actual as % of Approved- personnel emoluments by sub vote 2001/02 - 2005/06

2000/01

2001/02

2002/03

2003/04 2004/05 2005/06

General Administration and Planning

141 146 154 171 103.3 85.6

Curative Health 181 169 170 172 100.0 103.6

Preventive and Promotive

270 163 121 115 93.9 74.9

Rural Health Services

13 14 15 16 112.3 91.1

Health Training and Research

117 110 115 102 113.1

113.8

Medical Supplies Coordinator Unit

50 73 28 23 85.6 74.2

Total 101 97 100 100 100.8 100.2

/39

2.2.4 Appropriations in Aid (AiA) and Cost Sharing ( )

Table 2.2.5 shows the trends in total recurrent and development Appropriations in Aid (A in A), Table 2.2.6 the Appropriations in Aid implementation while Figure 2.9 illustrates the actual expenditure as a share of the printed estimates and approved expenditure respectively.

2.2.5 Appropriations in Aid (AiA)Table 2.10: Appropriations in Aid (KSh million)

2000/01 2001//002 2002/03 2003/042004/05 2005/06

Total Recurrent 73.0 66.3 90.0 57.1 61.4 27.1

Total development 154.2 1,277.5 485.0 328.1 252.9 505

TOTAL 227.2 1,343.8 575.0 385.2314.3 532.1

/40

2.2.6 Appropriations in Aid (AiA)2001/02 2001/02

2002/03 2002/03

2003/04 2003/04

2004/05 2004/05

2005/06 2005/06


Actual as % of Approved








Actual as %of Approved

Total Recurrent158 156 199 100 113 111 101 100

39 39

Total Development 53 47 16 13 10 14 6 12

15 11

TOTAL 55 49 18 15 12 16 8 15 16 12

2.2.5 Cost Sharing

Cost sharing in public health sector was mooted in the 1984/88 Development Plan and implemented in December 1989 to supplement and complement government resources allocated to the health sector. The revenue collecting health facilities are allowed to retain 75% for use in the improvement of their health care service provision. The remaining 25% of the revenue collected go towards financing the

/41

promotive and preventive services in the district. This is in addition to AiA funds. Reporting rates are crucial in providing accurate picture of trends in all cost sharing revenue collection aspects. Facilities are supposed to submit monthly reports on revenue collections, banking, payments and commitments, fee schedules, workloads, financial and workload targets.

Trends in cost sharing revenuesTable 2.2.7 shows the cost sharing revenue collection trends by province and year. During the financial year 2003/2004, the reported collected revenue was KSh 1,004.93million increasing to KSh 1,099.47million in 2004/05 and further to KSh 1,468.80 million in 2005/06. The rising trend in revenue collection can be attributed to increased reporting rates by facilities; enhancement, strengthening and efficiency improvements in revenue collection through among others, installation of cash registers in some hospitals with heavy workloads as well as, to a small extent, increases in fee levels. Eastern, Central and Rift Valley provinces dominated the total collections each accounting for nearly a half of total revenues collected in 2005/06.

Table 2.2.7 Total reported revenue collection by province and financial year (KSh million)Province 2001/2002 2002/03 2003/04 2004/05 2005/06Central 178.79 217.16 238.27 267.63 324.80Coast 140.12 162.91 128.42 160.01 151.90Eastern 141.55 201.37 212.12 207.50 393.40Nairobi 24.85 35.06 28.88 36.30 64.70North Eastern

5.43 7.20 8.62 17.32 22.50

Nyanza 93.87 121.47 94.28 128.24 131.10Rift Valley 181.92 217.53 227.82 210.22 281.10Western 16.83 70.23 66.52 72.25 99.30Total 783.37 1,032.94 1,004.93 1,099.47 1,468.80

The Ministry of Health through the Division of Health Care Financing continues with activities geared towards enhancing and strengthening revenue collection and efficiency improvements. The activities include installation of cash registers in hospitals with heavy workloads.

/42

3 Review of Projects/Programs related to the Ministry

3.1 Core poverty programs

The ministry of health for sometime has not changed her list of core poverty projects/programmes neither the list of those programmes related to the achievement of the MDGs. Most of these projects /programmes are recurrent in nature i.e. yearly or continuous, therefore their expenditure is from GOK. Table 3.1 below shows the trend of the expenditures of the projects/programmes in the ministry. It also reveals that what the projects/programmes spends is much below what they are allocated, these hinders the completion of the planned activities of these projects/programmes.

Table 3.1Summary of projects/programmes in the Ministry, 2003/04- 2006/07Project Name & category

Year started

Year of completion

Total Estimated Project cost

Total cumulative expenditure up-to 2005/06

Estimated cost of completion

Actual expenditure 2005/06

Allocation 2006/07

Proposed allocation 2007/08

National Aids Control Programme

Yearly

Continuous

9,609,115

9,125,563

483,552 9,125,563

10,684,547

11,401955

Sexually transmitted Infection

Yearly

Continuous

6,768,183

6,234,085.85

534,097.15

6,234,085.85

- -

District Hospitals

Yearly

Continuous

2,452,381,485

1,179,867,848

1,282,513,637

1,179,867,848

1,972,992,347

2,044,496,217

Mental Health Services

Yearly

Continuous

135,427,831

127,476,542

8,051,289 127,476,542

82,776,738

84,571,083

Spinal Injury Hospitals

Yearly

Continuous

13,301,061

13,199,514

101,547 13,199,514

12,134,443

12,552,080

Rural Health Centres and Dispensaries

Yearly

Continuous

2,176,117,141

2,160,735,680

15,381,461

2,160,735,680

3,588,338,473

4,937,453,015

Health development Project (DARE))

2001

2006 681,500,000

Establishment & equipping for parasite center (KEMRI)

20005

20006 20,000,000

22,000,000

22,000,000

Environmental Health

Yearly

Continuous

49,473,960

42,800,554

6,673,406 42,800,554

163,361807

222,0555,903

/43

Project Name & category

Year started

Year of completion

Total Estimated Project cost

Total cumulative expenditure up-to 2005/06

Estimated cost of completion

Actual expenditure 2005/06

Allocation 2006/07

Proposed allocation 2007/08

ServicesCommunicable & Vector borne Diseases

2000

Continuous

8,828,638,073.

109,013,022.60

8,719,625,050.40

109,013,022.60

150,900,005

189,851,105

Nutrition Programme

Yearly

Continuous

4,661,174

3,958,733.75

702,440.25

3,958,733.75

4,669,173

5,088,932

Vector borne Diseases control

2000

2006 11,477,511

10,781,196

696,315 10,781,196

- -

Family Planning Maternal &CHC

Yearly

Continuous

46,875,193

45,669,477.90

1,205,715.10

45,669,477.90

46875192

49,918,562

Rural Health Training & Demonstration Centres

Yearly

Continuous

43,672,013

42,305,246

1,366,767 42,305,246

43,680,732

52,569,087

Drugs Control Inspectorate

Yearly

Continuous

1,516,091

67,347.10

1,448,743.90

67,347.10

1,448,898

1,447,696

KEPI Yearly

Continuous

339,809,001

205,278,124.45

134,530,876.55

205,278,124.45

487,136,131

488,769,942

National leprosy &Tuberculosis

Yearly

Continuous

100,576,800

100,440,937.10

135,762.90

100,440,937.10

100,590,800

120,624,355

Kenya Medical Supplies Agency (KEMSA)

2004

Continuous

185,000,000

50,000,000

135,000000

50,000,000

- -

Specialized Global Fund

2005

Continuous

980,000,000

1,647,144,236

1,470,500,000

Special Global Fund TB

2005

Continuous

160,000,000

393,777,140

379,479,000

Special Global Fund Malaria

2005

Continuous

2,134,365,707

1,925,668,777

1,587,294,225

/44

3.2 Analysis of the outputs/outcomes related to these expenditures

Execution of a number of the development core poverty programmes within the MOH is likely to achieve the following outcomes: (a) support the ERS goal of delivering pro-poor services by ensuring increased coverage and access to health services; (b) strengthen and support the delivery of primary and preventive services; and (c) reinforce the referral system.

/45

The matrix below summarizes the programmes, goals, outputs and indicators.

Table 3.3: Summary of programmes, goals, outputs and indicators

Programme

Description

Goal/Objective

Output/outcome

Indicator

District Hospitals

Rehabilitation and Construction of facilities

Improve the capacity of all district hospitals infrastructure to deliver quality health services and strengthen health care delivery at the district level

Most health facilities rehabilitated, and improved to acceptable and working conditions.Quality health services available closer to the community through consolidating and reversing the deterioration of physical structures at all facilities

Rehabilitation i.e. repairs, re-roofing, re-painting, fencing, etc in identified district hospitals completed

Rural Health Centres and Dispensaries

Minor works, improvements and rehabilitation of rural facilities nation-wide

Improve rural health facilities in the country to serve rural poor better

All structures in rural health centres and dispensaries improved and rehabilitated Increased coverage of health services for the rural poorContribute to decongesting

All structures in rural health centres and dispensaries rehabilitated and improved

/46


Programme

Description

Goal/Objective

Output/outcome

Indicator

district hospitals and bring services closer to the people

Revolving Drug Fund

Procurement and distribution of drugs at affordable prices, infrastructure development, staff training, community mobilization and logistical support

Improve drug procurement and distribution, and affordability

Drugs available and affordable in the pilot district and its surrounding.Success and lessons from the pilot project replicated in other districts Successful implementation of the project, and its expansion to the other districts will strengthen KEMSA and make its cash and carry system effective

Health Development Project (DARE)

Is an intervention to support strategies to better target public subsidies to the poor and vulnerable

Create an enabling environment for decentralized management of integrated HIV/AIDS/TB and

Create decentralized organizational structures and management systems operational to enhance decentralization strategy

Increased immunization coverageIncreased contraceptive prevalence, etc

/47


Programme

Description

Goal/Objective

Output/outcome

Indicator

Reproductive Health Services within the districts.

within MOH

Supply of Medical Equipment

Improve the situation of medical equipment in existing hospitals

Increase the capacity of district hospitals to offer appropriate diagnosis and therapeutic services

Purchase and improve existing equipment in various district hospitalsAppropriate equipment purchased and delivered to district hospitals.

Equipment in most hospitals in better and working condition

Rehabilitation of Mortuaries

Improvement and face-lifting of all mortuaries country-wide

Improve mortuary services all over the country

All mortuaries country-wide improved, functioning and rehabilitated

New mortuaries erected where they do not exist.

Environmental Health Services

Health Services, sanitation, vector control, waste management, drinking water quality, housing improvement, pollution control, and health promotion

Reduce the incidence of environmental related diseases

Increased safe water and sanitation coverageReduced vector borne diseasesImproved human physical, biological and social environmentImproved sanitary dwellings,

Construction of demonstration facilities (latrines, domestic water supply)Disease surveillance, sanitary inspection and law enforcement

/48


Programme

Description

Goal/Objective

Output/outcome

Indicator

eating and work places

Mental Health Services

Provision of mental health care services to mentally sick patientsRenovation and rehabilitation of Mathare Psychiatric Hospital, and Gilgil mental hospital

To provide curative care services in Nairobi area, and help decongest KNH, and serve the densely populated eastern suburbs of Nairobi.

All structures and equipment in the hospitals rehabilitated.Equip mentally sick patients with skills for carpentry and general repairs of equipment.Improve the health care services for the mentally sick patients.

Hospital buildings fully renovatedRoads and fences at the hospitals repairedSewerage system at the hospitals overhauled.Community health workers trained on mental health care

Spinal Injury Hospital

Operations and maintenance of individual spinal injury health facilities

Improve and make accessible affordable health care services for the population with spinal injury.

Deserving spinal injury patients access health care services.Number of patients seeking care at these hospitals increased.

Operational requirements for the hospitals such as chairs for patients, drugs, etc in place.

Sexually Transmitted Infection

Reducing sexually transmitted diseases through research, clinical

Reduce the risk of STI transmission by providing preventive services

STIs reduced Public information messages, and education programmes

/49


Programme

Description

Goal/Objective

Output/outcome

Indicator

services to treat STDs.

Drugs, supplies, equipment to support treatment for STDs

Communicable and Vector Borne Diseases

Is an integrated disease surveillance and response involving disease preparedness and response, data management and information dissemination, laboratory support services, training and communication

Reduced mortality, disability and morbidity due to communicable diseases

IDRS expanded to cover up to 80% of the districts nation-wideCommunication infrastructure such as telephone, radio calls, faxes, and email network initiated in all districts.

Districts trained in emergency preparedness and response.Most health facilities have case information on priority diseases

Nutrition Programme

Reduce prevalence of iodine, Vitamin A and Iron deficiencies among mothers and children

Incidences of micro-nutrients deficiency related diseases in mothers and children reduced

Prevalence rate of iodine, vitamin A and Iron deficiencies reduced.

Advocacy conductedIEC materials on micro-nutrients deficiency

Food control

Food safety control,

Incidences of food

Improved sanitary

Health hygiene

/50


Programme

Description

Goal/Objective

Output/outcome

Indicator

Administration services

inspection and licensing, export certification and law enforcement

borne illness reduced

dwellings, eating and work placesEnhanced personal and food hygiene

promotionLaw enforcement Sanitary inspections Disease surveillance

3.3 Ministry’s On-going Projects

As shown on Table the Ministry of Health has a total of 126 ongoing projects mainly including rehabilitation and construction of buildings such as mortuary facilities, non-residential and residential buildings in various hospitals, health centres and dispensaries. These projects are those, which had allocations in the budget in 2005/2006, the allocations totalling to KSh 1,036,180,801 million.

Table4.1: Ministry of Health's Ongoing Projects - 2005/06

Project KSh Source

1 AFYA House 45,000,000 GOK

2 Coast Provincial general Hospital 35,000,000 Japan

3 Embu Provincial general Hospital 110,000,000 BADEA

4 Kianyaga Heath Centre 52,000,000 ADF

5 Ngano Health Centre 45,000,000 ADF

6 Kibuga Health Centre 45,000,000 ADF

7 Ngong Health Centre 45,000,000 ADF

8 Kenya Medical Research Institute 20,000,000 Japan

9 Rift Valley Provincial Gen Hospital 9,254,640 GOK

10 Kapsabet D.H 6,600,000.00

GOK

11 Nandi Hills D.H. 3,350,000.00

GOK

12 Iten D.H. 5,083,000.00

GOK

13 Kapenguria D. H 3,274,200.00

GOK

/51


Project KSh Source

14 Kitale District Hospital 8,800,000.00 GOK

15 Chebiemit District Hospital 7,158,650.00 GOK

16 Kabarnet District Hospital 3,240,000.00 GOK

17 Molo S.D.H. 3,200,000.00 GOK

18 Gilgil Hospital 3,000,000.00 GOK

19 Naivasha S.D.H 3,000,000.00 GOK

20 Kapkatet District Hospital 3,426,100.00 GOK

21 Nanyuki District Hospital 4,500,000.00 GOK

22 Eldama Ravine D. Hospital 4,000,000.00 GOK

23 Narok District Hospital 4,500,000.00 GOK

24 Kilgoris D.H. 7,000,000.00 GOK

25 Longisa D. Hospital 2,635,000.00 GOK

26 Kajiado District Hospital 4,000,000.00 GOK

27 Loitokitok Sub-District Hospital 3,950,000.00 GOK

28 Maralal D.H. 4,077,400.00 GOK

29 Baragoi SDH 4,000,000.00 GOK

30 Kapkatet District Hospital 5,021,000.00 GOK

31 Nanyuki District Hospital 6,000,000.00 GOK

32 Eldama Ravine D. Hospital 240,000.00 GOK

33 Lodwar District Hospital 3,274,200.00 GOK

34 Eldoret S.D.H. 8,800,000.00 GOK

35Londiani SDH 7,158,650.00

GOK

36Kericho District Hospital 2,500,000.00

GOK

37Kisumu District Hospital 5,960,000.00

GOK

38New Nyanza PGH 9,831,838.00

GOK

39Kombewa SDH 7,000,000.00

GOK

40Migori District Hospital 10,622,430.00

GOK

41Awendo SDH 1,500,000.00

GOK

42Rongo SDH 1,500,000.00

GOK

43Homa bay District hospital 5,000,000.00

GOK

44Siaya District Hospital 4,180,000.00

GOK

45Yala SDH 5,500,000.00

GOK

46Nyando DH 7,500,000.00

GOK

47Muhoroni SDH 500,000.00

GOK

48Ogembo D.H 8,604,050.00

GOK

49Bondo D.H. 7,628,200.00

GOK

/52


Project KSh Source

50Madiany S.D.H. 4,200,000.00

GOK

51Rachuonyo DH 5,262,000.00

GOK

52Suba D.H 6,000,000.00

GOK

53Kuria D.H. 5,000,000.00

GOK

54Kisii D.H 2,000,000.00

GOK

55Keumbu SDH 3,800,000.00

GOK

56Nyamira DH 3,663,000.00

GOK

57Nyeri PGH 14,926,345.00

GOK

58Thika district Hospital 7,116,330.00

GOK

59Gatundu Hospital 4,000,000.00

GOK

60Muranga D.H 6,000,000.00

GOK

61Muriranjas SDH 3,560,000.00

GOK

62Karatina D.H 3,780,000.00

GOK

63Mukurweini SDH 3,880,000.00

GOK

64Othaya SDH 6,000,000.00

GOK

65Kiambu District Hospital 5,550,000.00

GOK

66Tigoni SDH 5,450,000.00

GOK

67Kerugoya District hospital 5,809,477.00

GOK

68Kimbimbi SDH 7,000,000.00

GOK

69Nyahururu District Hospital 7,378,210.00

GOK

70Olkalou SDH 2,000,000.00

GOK

71Maragua District Hospital 9,288,608.00

GOK

72Runyenjes SDH 6,000,000.00

GOK

73Embu PGH 5,406,360.00

GOK

74Nyambene D.H. 11,635,000.00

GOK

75Miathene SDH 4,000,000.00

GOK

76Chuka District hospital 6,514,600.00

GOK

77Magutuni SDH 4,000,000.00

GOK

79Meru Central District 8,752,600.00

GOK

80Githongo SDH 2,000,000.00

GOK

81Kanyakine SDH 2,580,000.00

GOK

82Isiolo District Hospital 3,800,000.00

GOK

/53


Project KSh Source

83Marsabit District Hospital 5,152,000.00

GOK

84Moyale D. H 3,000,000.00

GOK

85Garbatula S.D.H. 4,975,000.00

GOK

86Tharaka District 8,240,000.00

GOK

87Kitui District Hospital 7,270,000.00

GOK

88SiakagoD.H. 6,200,000.00

GOK

89Ishiara SDH 2,000,000.00

GOK

90Makueni D.H 2,200,000.00

GOK

91Makindu SDH 6,500,000.00

GOK

92Machakos General Hospital 12,122,000.00

GOK

93Mbooni SDH 2,000,000.00

GOK

94Mwingi District Hospital 8,024,952.00

GOK

95Tseeikuru SDH 6,000,000.00

GOK

96Kakamega PGH 1,740,000.00

GOK

97Malava sub-district Hospital 2,009,170.00

GOK

98Lumakanda D Hopsital 8,873,400.00

GOK

99Mt. Elgon District Hospital 3,236,000.00

GOK

100 Teso District Hospital 8,943,885.00

GOK

101 Bungoma District Hospital 24,664,360.00

GOK

102 Webuye SDH 4,500,000.00

GOK

103 Port Victoria SDH 6,618,425.00

GOK

104 Alupe SDH 1,500,000.00

GOK

105 Vihiga District Hospital 3,370,000.00

GOK

106 Butere District Hospital 6,000,000.00

GOK

107 Busia District Hospital 5,047,000.00

GOK

108 Coast PGH 10,586,865.00

GOK

109 Hola D.H. -

GOK

110 Ngao SDH 16,000,000.00

GOK

111 Wesu D.H. 3,000,000.00

GOK

/54


Project KSh Source

112 Voi DH 7,573,930.00

GOK

113 Taveta Hospital 2,396,114.00

GOK

114 Kwale D.H. 10,500,000.00

GOK

115 Kinango SDH 5,000,000.00

GOK

116 Msambweni S.D.H 13,460,560.00

GOK

117 Kilifi D.H. 2,000,000.00

GOK

118 Malindi D.H. 2,000,000.00

GOK

119 Port Reitz D.H. 2,000,000.00

GOK

120 Lamu D.H. 2,000,000.00

GOK

121 Garissa DH 6,467,952.00

GOK

122 Wajir D.H 4,245,450.00

GOK

123 Masalani D.H 6,000,000.00

GOK

124 El Wak SDH 6,215,000.00

GOK

125 Rhamu SDH 9,655,700.00

GOK

126 Mandera D.H. 4,000,000.00

GOK

TOTAL (KSh) 1,036,180,801Source: 2005/06 Estimates of Development Expenditure

3.4 Stalled Projects

At the same time, there are a total of about 86 stalled projects whose cost of completion is estimated at Kshs.2.12 billion (Annex 1). These stalled projects bear a number of distinct features:

the list include a range of projects whose start up date is early as 1981, and others as recent as 1998;

the completion status is varied, and range from as low as 10% to over 90%;

On average, the majority (almost 79%) of the stalled projects (whose status is known) are 50% and above complete;

Despite being incomplete, the rise in costs to completion may be associated with interest on contract violations, and lack of budget allocations to ensure they are completed.

/55

However, a number of the stalled projects have not been abandoned since they were included in the budget estimates for 2004/2005 as shown in Table 6 –

3.5 New projects TO BE INITIATED IN 2006/07 CHAO TO PROVIDE INFORMATION-CHERUYOIT TO FOLLOW UP – NO NEW PROJECTS SO FAR

3.6 Weakness in Project implementation

Judging from the long list of stalled projects, the varied status of completion, and amounts of money needed to complete them, including the large difference between the original and current costs, a number of weaknesses become apparent:

A clear policy or decisions to check cost escalations on these projects seems to be lacking. This may be a government-wide problem and not MOH specific.

Similarly mechanisms for monitoring and evaluating the progress of projects seem to be lacking. Such a mechanism, if combined with an appraisal process, would allow decisions to be made on current and ongoing projects before new commitments are made, and additional project costs included in the budget for the MOH.

The appraisal should include stiff criteria for verifying new projects. Where possible, completion of ongoing projects ought to be part of the criteria and conditions for initiating new ones.

/56

4 Pending BillsUnpredictability of the budget leading to, in particular, variations between the budget, and budget out-turns leaves the wide gap between estimates and actual expenditures. Together with delays caused by the existing capital project procurement policy, the accumulation of pending bills has become a problem, and to non-completion and stalling of development projects.0.As summarized in Table 5.1, the MOH accumulated a total of KSh. 158.3 million in pending bills for both recurrent and development for the period under review . The larger proportions (96%) of the pending bills were for development costs, mainly for rehabilitation and construction. It will be noted that pending bills have increased by over 40% from last year and this is likely to increase further if bills are not paid in advance. There is a down ward trend of bills under utilities in the recurrent vote but with the development vote the trends is increasing. This calls for more funds to be allocated to the development vote in order to finish the planned projects in advance.

Table 5.12004/05 2005/06

Vote head/typeDescription mount (KSh) Amount (KSh)

Recurrent

Utilities (mainly water)

57,781,145 35,275,301

Telephone 11,000,000 4,527,230Other 25,449,434

Total recurrent 94,230,579 39,802,531

Development 3,447,390 118,479,103.30

Total (recurrent + Development)

97,677,969

158,281,634.30

% of Total MOH expenditure

0.5 0.07

5.1 Recommendations

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Further disbursements should be accompanied by implementation guidelines especially for RHF’s

The DHMB’s should be enabled/empowered to oversee implementation of projects and defect omissions/mistakes early enough i.e not leaving every thing to the ministry of Roads and public works alone

Processing of AIE’s and subsequent of funds should be done within the 1st quarter of the Financial year allows proper planning/adequate consultation with Management Committees

Facilities that were not funded in 2005/06 should be prioritized in 2006/07(see attached list).

Improving budget predictability. Recognizing and increasing the budget for operation

and maintenance expenditures such as supplies, utilities, communication, etc. At present, approved budgets are not matched with timely release of exchequer funds by the government.

A review of current procedures governing the release of certified and voted funds is needed in order to avoid delays, and to facilitate overall improvement in the implementation of the budget.

As revenues and resources for health improve, the MOH needs to add medical supplies, maintenance and repairs especially at the rural health facilities to its list of protected budget items as is the case for selected expenditures for core poverty programs

5 Analysis of Ministry outputs and corresponding performance indicators

5.1 Output targets

Table 5.1 shows the outputs and targets for selected indicators. These indicators are intended to measure the performance of the MoH as past of its commitment to the Economic Recovery Strategy (ERS).Table 5.1: Health Sector Indicator Targets7

7 The BOP did not extend the targets to 2008/09.

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Indicator Measure Base line2003(%)

2005Achieved8

2006Target

2007 Target

1. Proxy for Infant Mortality

Fully Immunized Children (FIC) as a % of under-one population

57 61 67 70

2. Proxy for HIV/AIDs prevalence

Percentage of pregnant woman attending ANC who are aged 15-24 who are HIV-infected

10.1 6.4 8.4 8

3. Proxy for Maternal Mortality

Percentage of ANC coverage (4 Visits)

54 56 65 70

4. Proxy for Burden of Disease

Inpatient malaria morbidity as percentage of total in-patient morbidity

19 18 15 14

5.2 Overview of Sector Performance Indicators and Targets

Overview of Sector Performance Indicators and Targets, NHSSP II/AOP 2, 2006/07

Indicators

Baseline

National Targets 05/06

Achievement

Achievement for

reporting districts

(61)

Projected national

achievement

Performance against

target

Below 80% Achievement

%Deliveries conducted by skilled health staff 42% 51% 15% 15% 30%

District Aqua Laboratories in place 80 28 28 35%

# School children correctly de-wormed at least once in 2005/06 25% 35% 7% 13% 36%

# HIV+ve patients starting with ART 8,000 95,000 38,320 38,320 40%

% Pregnant women sleeping 0.44 44% 20% 20% 45%

8 Current status(achievements)

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under LLITN

# LLITN distributed to children under 5 yrs 250,000 3,400,000 1,181,959 1,798,739 53%

% WRA receiving FP commodities 10% 20% 11% 11% 57%

% Pregnant women attending four ANC visits 54% 70% 44% 44% 62%

# Condoms distributed (million)

80,000,000

90,000,000 37,422,850 66,030,516 73%

% Children < 1yr vaccinated against Measles 74% 84% 64% 64% 76%

Above 80% Achievement

% Children fully immunized at 1 year of age 58% 68% 56% 56% 83%

Blood collected screened for HIV 0.98 1 1 1 100%

Regional Food/Bacteriological Lab. Established 8 7 8 100%

% Newborns that receive BCG 84% 90% 99% 99% 111%

# Health Facilities providing Basic/Comprehensive Emergency Obstetric Care (BEOC / CEOC) 9% 15% 18% 18% 122%

# Houses sprayed with IRS 2,500 200,000 367,000 367,000 184%

% Pregnant women received IPT 2x 4% 20% 43% 43% 214%

LLITN distributed to pregnant women 55000 200000 251,872 456,771 228%

% House Holds implementing hygiene practices 25% 58% 58% 234%

# HF providing treatment as per IMCI guidelines 2% 10% 35% 35% 353%

# HF offering Youth Friendly Health Facilities 5 5 47 47 940%

# CORPs selected and trained 100 10024 10024 10024%

5.3 Links Budget allocation to Output Delivery

Public management promotes a direct link between results based public health sector management and the budgetary process. Health budgets are allocated based on the variables of which some are outputs. The budgeting system quite rightly assumes that budgets cannot be realistically based on the delivery of outcomes. These are often medium term objectives and are influenced by a number of variables, some not within the control of the health sector; and their monitoring is a very complex task.

The direction and strategies outlined in NHSSP II are to be implemented through development and implementation of annual operational plans (AOPs). In addition, a four-year Joint Programme of Work and Funding (JPWF), developed concurrently with the plan, outlines the interventions the sector will focus on in the medium term,

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their costs, financing and finance gaps. The JPWF also describes the financing strategy the sector will use to mobilize the resources needed to close the gaps. The linkages among NHSSP II, the JPWF and the various AOPs are illustrated in Section 2.5.

Among others, the elements of NHSSP II are:

Creating linkages from NHSSP II to the overall development objectives as expressed in the Economic Recovery Strategy for Wealth and Employment Creation 2003–2007 (ERSWEC), and the achievement of the Millennium Development Goals (MDGs).

Renewing attention to the right to health care and the importance of good health at the household, family and community level.

Introducing the Kenya Essential Package for Health (KEPH), which integrates all health programmes into a single package to improve the health of the population in the different stages in their life cycle and incorporates the various systems that will support KEPH.

Proposing to change the governance of the sector by institutionalizing and improving the relations between MOH and all stakeholders.

Starting to apply public sector reforms within the health sector (like performance-based contracts for all those responsible in the civil service).

Initiating a sector-wide approach (SWAp) in the health sector, through joint planning and joint performance monitoring, as well as a process to arrive at a harmonization of funding arrangements.

5.4 Expected Outputs and Outcomes 2006/07

5.4.1 Human ResourceIn order to address the long-term manpower needs for the health

sector, an assessment is being conducted to identify the human

resource requirements to meet the MDGs. This report is expected to

form the basis for a human resource development policy including

training need assessment.

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5.4.2 Drug ProcurementThe process of drug procurement need to be made transparent in

order to ensure the public gets value for money. Enhancing

transparent and reducing opportunities for rent seeking are some of

the conditions precedent to Kenya accessing the Millennium Challenge

Account funds. The ministry will put mechanisms top ensure that

information on drug tenders are published and hosted in the website.

5.4.3 Access to ARVsUser fees charged to HIV/AIDS patients are hindering access and

constraining the attainment of the 3 by 5 objective. In order to remove

this barrier, user fees have been reduced to Ksh 100 per month. It is

expected that this policy initiative will enable us provide ARVs to more

than 95,000 people by 2006.The ministry is putting in place measures

to ensure access for children suffering from HIV/AIDS.Currently 10000

children are on ARVs

5.4.4 Restructuring of the MinistryThe current structure of the Ministry is not appropriate for efficient

delivery of services. In the restructuring process, the focus will be to

have a leaner centre, which will provide policy and regulation, while

building capacity at the district level to deliver healthy care services.

To improve access to health care the Ministry will develop a policy

based on facility workload, distance to the facility, human resource

deployment and catchment area. The new organogram will be part of

the Ministry five-year strategic plan.

5.4.5 Restructuring of Parastatals

The ministry will ensure that the performance contracts are adhered

to. The Ministry is also exploring ways of converting KNH to a fully-

fledged teaching hospital

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6 Public Expenditure Management (PEM)

Public expenditure management (PEM) is a central instrument of economic and development policy. Key goals of PEM are fiscal discipline, strategic resource allocation and good operational management. Effective PEM is also a key component in good governance, which rests upon the 'four pillars' of accountability, transparency, predictability and participation.

Accountability holds officials responsible for their actions. Transparency involves ensuring access to relevant information. Predictability results from an environment in which laws and regulations are clear, known in advance, and uniformly and effectively enforced. Participation requires the existence of channels through which reliable information is provided, enabling all stakeholders at all levels to be involved in the consultation and decision-making process.

On the whole the PEM framework pursued by the MoH is based on the following objectives:

Fiscal discipline, or living within the available resources; Allocative efficiency, or spending money on the right things; and Operational efficiency, or obtaining the best value for money.

It is proposed that monitoring of the budget will be done by conducting a Public Expenditure Tracking Surveys (PETS), which will provide quantitative and qualitative evidence on budget execution and accountability and transparency of transactions.

The Public Expenditure Review and PETS can assess the effectiveness of public expenditure and makes recommendations as to how public funds can be better spent.

Another way of monitoring the over all use of resources in the health sector is the use of a National Health Account (NHA). A NHA is a tool for gathering and analysing health expenditure data for a given period. It asks the fundamental questions: who pays, how much and for what? NHAs link ultimate sources of funds to financial agents and claims on pending by different users. “Users” can be classified as providers (e.g. government health centres, or private practitioners), functions (curative, preventive), service delivery level, (tertiary, secondary), inputs (transport, salaries), different socio-economic groups (rural/urban, wealth, gender, age), geographical locations and disease profiles.

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6.1 Budget Preparation Process

The budget preparation process should aim at (i) ensuring that the budget is appropriate to macro-economic objectives and that expenditures are controlled; (ii) allocating resources to programs that fit the policy objectives in the health sector; and (iii) securing conditions for operational efficiency. During budget preparation, trade-offs and prioritisation among programs are made to ensure that the budget fits government priorities.

Treasury in consultation with stakeholders prepares the Budget Outlook Paper (BOP) ready for release in December. This Paper is necessary because it provide the ceiling for each ministry.

The BOP provides three-year medium-term spending projections by sector. These are necessary to demonstrate to the public the desired direction of change. By illuminating the expenditure implications of current policy decisions on future years budgets, multi-year spending projections allow sectors to evaluate cost effectiveness and to determine whether they are attempting to undertake more than they can afford.

NHSSP II reinforces the decentralization process, with lower levels setting their own priorities according to their own needs and subsequently developing appropriate interventions. This is in line with both the Kenya Health Policy Framework for 1994–2010 and the government’s decentralization policy, articulated in the District Focus for Rural Development Strategy.

In this regard, the development of AOP 2 adopted a bottom-up planning process, beginning with revision and preparation of guidelines and planning tools. The district health plan format was re-designed to respond to the KEPH concept. This was followed by dissemination of NHSSP II to DHMTs, PHMTs, and the central divisions and programmes. An extensive training programme provided the necessary support to build the capacity of all participants to carry out their tasks. It is envisaged that this approach will greatly strengthen the various planning levels and in addition promote ownership of developed plans.

6.2 Results-Oriented Public Expenditure Management

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Public Expenditure Management (PEM), as a major component of the reform Programme, continue to make use of the following mechanisms:

Use of the budget as instrument for ensuring desired results; Strengthening of existing structures to advocate and implement

reforms; and The establishment of clear targets and assessment mechanisms

to ensure transparency.

Results-oriented (or ‘performance’ or ‘output’) budgeting is the planning of public expenditures for the purpose of achieving explicit and defined results. These results may be policy objectives (‘outcomes’), or the ‘outputs’ of routine public service activities intended to contribute to policy goals, or ‘intermediate outcomes’ which represent major stepping stones in service delivery towards these goals.

Performance budgeting and management help to: a. Clarify policy priorities, b. Focus expenditures more tightly on priorities, c. Inform and motivate programme managers and service

Providers,d. Identify the causes of good and bad performance and

thereby reduce waste and increase impact, ande. Facilitate cross-institutional working. They are easiest to

apply and most fruitfully applied to the production of services for the public.

6.2.1 Results-Based Management

The GOK has adopted the results-based management (RBM) approach as a leading principle in its efforts to enhance the productivity and improve the performance of the various ministries. The MOH is one of the ministries where RBM was introduced in an early stage, when the previous Permanent Secretary (PS) signed a performance contract spelling out the targets and outputs the MOH had to achieve within one year (2005/06).

7 Human Resources Development and Capacity BuildingHuman resource development is increasingly being recognised as key to improved health service delivery and health sector transformation. Policies do acknowledge that health is a human system, and that

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reforms have to address themselves centrally to the personnel staffing the service, improving planning, capacity and management. Yet, there is concern about the equitable distribution of the key health personnel.

By far, the most significant component of any health system is its health personnel. Without a foundation of skilled human resources, health care systems cannot function adequately or effectively, particularly in the public sector and at the primary level of care.

No doubt, health systems can improved in their performance when there are improvements in the deployment and orientation of health personnel towards major health problems and improvements in the effective use of staff time. Research from other countries shows a correlation between quality of care, health care outcomes and the availability of health personnel9, 10.

7.1 Service Delivery Inputs

The NHSSP II recognizes that human resources, infrastructure and commodities are the primary tangible inputs into the delivery of health care services.

Availability of skilled human resources in adequate numbers is critical for the realization of the sector mission to deliver quality and accessible health services, more so if KEPH is to be implemented as planned.

There is an apparent gap in human resources when compared with norms and standards and the targets to be achieved in the next four years. A recent survey of the MOH personnel showed a necessary staff establishment of 44,813, of which 35,627 posts are filled (80%).

The same survey also brought out important disparities in the distribution of staff, with rural and isolated areas having very few staff. Moreover, the environment in which health personnel work is considered poor. In particular, the physical infrastructure is inappropriate and much of the equipment is lacking or non-functional. Other constraints include:

9 Mercer H, Dal Poz M, et al. Human Resources for Health: Developing Policy Options for Change. Geneva: World Health Organization; 2002. URL: http://www.who.int/entity/hrh/documents/en/ Developing_policy_options.pdf

10 ICN. Position Statement: Nurse Retention, Transfer and Migration. Geneva: International Council of Nurses; 1999.

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MOH cannot control the number of staff it has, as human resource management functions are decided at the level of the Directorate of Personnel Management (DPM).

There is currently an embargo on the recruitment of new staff, although special funds (like the Global Fund to Combat AIDS, Tuberculosis and Malaria – GFATM – and the President’s Emergency Plan for AIDS Relief – PEPFAR) allow for additional staff on a temporary basis.

There is under utilization of staff in some areas (rural and isolated), excess workload in others (district and provincial hospitals), and critical shortages in level 2 facilities (50% of the dispensaries had only one staff member managing the health facility).

Attitude of staff is not always positive (due to long hours, low salaries, lack of equipment, low morale). This has an effect on staff–patient relations.

7.2 Human resources situation

Kenya faces a variety of health personnel problems. These include an overall inadequate number of personnel in key areas of the health sector; an inequitable distribution of those health personnel who are available; and an attrition of trained personnel from the health sector and from the country. Yet the challenge is even more daunting when seen in the light of the additional health facilities that are being put up under CDF and the MoH expected to take over and staff and equip them. But all in all, MoH is committed to fundamental reforms to improve efficient of health services in the health system, including its human resources.

The mal-distribution of health care personnel occurs mainly between: Public and private sectors; Urban and rural areas;

In a number of instances, key health personnel shortage is more as a result of mal-distribution of human resources rather than actual or absolute numerical shortages. The human resource disparities occur in terms of:

Geographical spread; and

Professional category

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Inequitable distribution of human resources is an inter-provincial as well as an intra-provincial problem. Table 7..2 shows the distribution of the MoH health personnel. Of all health professionals working in Kenya public health sector, the North Eastern Province has:

1.3% of all doctors; 2.0% of all nurses

Table 7.2: Total Number of Personnel by Profession and Province in 2004-2005

Staff type

Nairobi

Central Coast Easter

n

North Eastern

Nyanza

Rift Valley

Western Total

KNH

Rest of Nairobi

Total

Moi Referral & Teaching Hosp

Rest of Rift Valley

Total

Doctors 218

328

546

156

115

178

20

104

55

231

286

81

1,486

Clinical officers

61

125

186

278

212

336

78

285

69

651

720

221

2,316

Registered nurses

866

250

1,116

561

343

487

87

341

206

775

981

257

4,173

Enrolled nurses

824

670

1,494

2,313

1,099

2,365

262

1,599

285

3,210

3,495

1,526

14,153

Pharmacists

10

104

114

25

12

21

1

12

3

28

31

9

225

Pharmaceutical technologists

45

31

76

22

26

47

18

25

23

72

95

21

330

Laboratory technologist

115

132

247

216

102

201

26

179

35

315

350

132

1,453

Laboratory technicians

30

69

99

37

93

69

19

40

10

168

178

45

580

Radiographers

35

18

53

49

27

50

9

41

22

75

97

22

348

Health administrative officers

32

14

46

24

13

26

1

14

30

24

54

16

194

Public health officers/public health technicians

20

228

248

652

340

664

118

505

10

1,370

1,380

376

4,283

Nutritionists

56

50

106

64

29

42

9

24

31

119

150

26

450

Social workers

28

10

38

1

-

2

-

2

22

5

27

4

74

o) All others

2,476

1,321

3,797

1,356

736

1,473

149

1,280

1,010

1,718

2,728

686

12,205

TOTAL 4,816

3,350

8,166

5,754

3,147

5,961

797

4,451

1,811

8,761

10,572

3,422

42,270

7.3 Human resource disparities

Table 9.1 shows that mal-distribution of professionals is worse in

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provinces with:

Sparsely populated areas characterized by vast distances, especially North Eastern province,

Deep-rural and remote districts with lack of general infrastructure

Various types of health facilities, particularly dispensaries

Table 9.2: Selected health personnel, Rates per 100,000 population Staff type Nairobi Centra

lCoastEaster

nNorth Eastern

NyanzaRift Valley

Western

Total

Doctors 546 156 115 178 20 104 286 81 1,486Number per 100,000 population

19.8 3.9 3.9 3.5 1.4 2.1 3.4 2.1 4.4

Clinical officers 186 278 212 336 78 285 720 221 2,316Number per 100,000 population

6.8 6.9 7.2 6.6 5.4 5.8 8.6 5.7 6.9

All Nurses (Registered & Enrolled)

2,610 2,874 1,442

2,852 349 1,940 4,476 1,783 18,326

Number per 100,000 population

94.8 71.2 49.3 55.7 24.3 39.5 53.5 45.9 54.8

Pharmacists 114 25 12 21 1 12 31 9 225Number per 100,000 population

4.1 0.6 0.4 0.4 0.1 0.2 0.4 0.2 0.7

Source : Human resource Mapping 2003 Table 9.1 reveals inequities in access to health professionals in the public sector. Nairobi, including KNH (19.8 per 100,000 population) and Central (3.9) and Coast (3.9) provinces are better staffed with doctors than the other provinces.

In Western and Nyanza provinces, there is one public sector

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doctor for every 47,000 population. In the North Eastern Province the ratio is much worse with one doctor for every 72,000 people in the public sector.

The North Eastern Province has one public sector nurse per 4,100 populations, compared to central province, where there is 1 nurse for 1,400 people, and for every 1050 population in Nairobi,

There is only one public sector clinical officer for every 18,400 people living in the North Eastern Province, for every 14,500 people in central, and for every 13,800 people in the coast province.

It should be notes that although Nairobi is comparatively well resourced with doctors, many of these doctors work at tertiary level (KNH).

A number of strategies have been implemented to increase the number of key health personnel in the public sector including employment of more key health personnel e.g. nurses; laboratory personnel under the PEPFAR /Clinton Foundation arrangement.

As seen from Table 9.3: A total of 7,450 staff has been recruited during the period 2001-

2006

There was no discrimination in the recruitment.

Table 9.3: Number of Staff employed by year and typeCadre 2001 2002 2003 2004 2005 2006 TotalClinical Officer 119 158 93 201 24 272 867Enrolled Nurses 536 362 240 400 220 1,791 3,549Nursing Officers 229 236 169 356 94 542 1,626Medical Officers 116 158 261 162 248 309 1,254Medical Laboratory Technologists

0 0 0 0 8 146 154

TOTAL 1,000 914 763 1,119 594 3,060 7,450

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7.4 Impact of HIV/AIDS on Human Resources

Any human resource plan for health in Kenya must take into account the increased load placed on existing staff due to HIV/AIDS, and the attrition of health care workers due to AIDS related mortality.

In a study on human resources mapping, obtaining information on short-term and long-term sickness proved very difficult during the survey with the MoH staff reluctant to talk about staff affected by HIV/AIDS, yet AIDS and AIDS-related illness is known to be affecting significant numbers of medical staff. All in all, information about all sickness issues – whether short- or long-term is essential to inform HR planning. A VCT centre has been established at the MOH Headquarters and is operational. The facility is open to both staff and the general public.

8 Implementation of Recommendations of the 2006 PER

The 2006 Ministry of Health PER is part of the continuing series of MPER, and builds on the previous year PER. While its production was hampered by numerous constraints, notably data and time, it made several key recommendations that have been acted upon during the year by the Ministry of Health. These are summarised in point form below as an Action Plan and the Activities and Broad Actions to implement them.

.

8.1 Action plans for implementation of 2006 MPER

The level of Government funding on health has increased in line with the ERS. However, the allocations are only 8.4 percent of the central Government allocation a figure far below the Abuja declaration targets.

The personnel costs take 53% of MOH recurrent expenditure. In 2004/05 spending on personnel represented 52 percent of the total recurrent funding. , suggesting that these costs may be stabilizing;

Curative Health service accounted for about a half (50.6%) of the recurrent expenditure on health, although this share has been falling since 2000/01 and stood at less than a half in 2004/05.

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The share of Kenyatta National Hospital decreased from 16.2% in 2002/2003 to 15.3 percent in 2004/05 and further to 14.5% in 2005/06.

Substantial expenditure on Development were directed towards the rural health services increased from 26.8% in 2004/05 to 28.2% in 2005/06 and about 54 percent to Preventive and Promotive while just under 10% went to the strengthening the Curative Health services.

Cost sharing accounted for about 12 percent of the ministry recurrent budget. The bulk of these collections are in hospitals. The health facilities are witnessing an increase on waivers and exemptions since patients are unable to pay. An arrangement need to be made to compensate health facilities for loss in revenue. There is need to critically examine utilization of these funds in light of the many audit queries being raised by Controller and Auditor General. In response to this, the Ministry has intensified monitoring and supervision systems on collection, custody, control, programming and expenditure of funds. Corrective measures have been taken on areas that funds have not been accounted for.

Release of money through AIEs to the districts has been a bottleneck to expenditures at the district level. In 2005/6 Treasury allowed funds to be disbursed on pre-financing arrangements. This has ensured that facilities receive an AIE accompanied with a cheque to facilitated programmes implementation and expenditures.

It is hoped that in future grants will be issued to health facilities once a legal framework is developed. Currently, the Ministry has developed a position Paper and Guidelines in the flow of funds to the rural health facilities.

8.2 Activities and Supporting Actions

Develop a Geographical information system to provide district profiles on resource available, actors, and health indicators for better planning and resource allocation;

Develop a manpower projection model and a decentralisation policy; and

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Review resource allocation criteria. Strengthen the DHMBs to oversee health care services at the

district level;The BHMBs have been reconstituted and will be trained along with the management committees early in 2006.

8.3 Timeframes and targets

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9 Challenges and Constraints

9.1 Integrating NHSSP II and AOPs into the Annual Budget

The introduction of the NHSSP II, AOPs, BFR and Performance Contracts in 2005 has changed the landscape for the Ministry of Health budgeting. The challenge for the Ministry of Health is to ensure that the budget will reflect these developments.

The development of the KEPH provides a set of programmes to deliver the long-term goals of the Ministry of Health through the setting of short to medium term objectives. These are centred on the life cycle interventions:

Pregnancy, delivery and the newborn child (up to two weeks of age) Early childhood (3 weeks to 5 years) Late childhood (6 to 12 years) Adolescence (13 to 24 years) Adulthood (25 to 59 years) Elderly (60 years and over)and the five clusters of interventions Safe motherhood and reproductive health Child health promotion Malaria control HIV/AIDS/STI and TB control Sanitation and food safety

While these interventions will be delivered mainly through the three lower levels of care: community, dispensary and health centre11, the KEPH targets also refer to the delivery through district and other higher level hospitals.

The challenge is to integrate the five clusters of interventions to the budgets of the delivery institutions and link them to the output indicators for the six levels of the life cycle. This will then tie in the inputs in the budget to specific programmes (cluster of interventions) through activities carried out in the various institutions to achieve the output targets of the six elements of the life cycle.

This will then link the annual budget to the objective of Results Based Management as expressed in the AOP and the various Performance Contracts.

11 As reported in Chapter 1

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9.2 Reviewing Targets

There is plethora of targets established for the Health sector. Chapter 9 reports on those set in the MTEF and ERS. Annexes I and II present those for KEPH and Performance Contracts. In addition there are targets expressed in the MDGs, although these are essentially subsumed in the MTEF and ERS targets.

Table 9.2 of AOP II Leadership outputs has the following output as part of the work programme, which has yet to be achieved.

Outputs for 2005/06

Time Frame 2006/07

I II III IV

6.1. Leadership outputs

75

Indicators, targets and priorities are harmonised with NHSSP II, ERS and MDG. X

The Performance Contracts are a mixture of process and procedural targets as well as operational ones. The operational ones are similar in style to the KEPH targets in that the measure output related to some heath indicator. However they are not necessarily the same targets.

It will be important that operational targets set in KEPH and in the Performance Contracts are the same given the challenge relating to the budget in the previous section. Therefore, the review and harmonisation of targets established in AOP II takes on a greater urgency and should be completed.

These are two challenges set out in this section. The constraints in achieving them will centre on the allocation of sufficient skilled personnel to the task and enough time for them to complete the task. This would suggest that a task force be established, but properly resourced. The challenges are complex and should not be hurried. They should be carried out in 2007 as inputs to the 2008 PER and the 2008/09 Budget.

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10 Conclusions and Key Recommendations

By the 1970s, Kenya had built a health sector that performed relatively well compared to neighbouring countries, and some of its indicators were among the best in sub-Saharan Africa. However, these substantial gains made during the 1970s and the 1980s have been eroded to reflect a downward trend in health at the start of the new millennium. However there are important regional differentials; North Eastern, Coast, Nyanza and Western Provinces having the worst health indicators. Unless drastic actions are taken Kenya is unlikely to achieve the MDGs.

Although the level of Government funding on health has increased in line with the ERS, these allocations are only 8.73 percent of the central Government expenditures a figure far below the Abuja declaration targets.

The personnel costs take 53% of MOH recurrent expenditure. In 2004/05 spending on personnel represented 52 percent of the total recurrent funding. , suggesting that these costs may be stabilizing;.

Curative Health service accounted for about a half (50.6%) of the recurrent expenditure on health, although this share has been falling since 2000/01 and stood at less than a half in 2004/05.

The share of Kenyatta National Hospital decreased from 16.2% in 2002/2003 to 15.3 percent in 2004/05 and further to 14.5% in 2005/06.

Substantial expenditure on Development were directed towards the rural health services increased from 26.8% in 2004/05 to 28.2% in 2005/06 and about 36 percent to Preventive and Promotive while 22% went to the strengthening the Curative Health services.

A comparison of the printed estimates and actual expenditures reveals that, the disbursement rates of development expenditure have been low. However, for the recurrent budget, the divergence between the printed or approved estimated and the actual expenditures is small – within a range of ±10% - with large over-spending in some sub votes have been cancelled out by large under-spends in other sub votes. With respect to development expenditures, the pattern is generally one of large under-spending.

Cost sharing accounted for about 12 percent of the ministry recurrent budget. The bulk of these collections are in hospitals. The health facilities are witnessing an increase on waivers and exemptions since

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patients are unable to pay. An arrangement need to be made to compensate health facilities for loss in revenue. There is need to critically examine utilization of these funds in light of the many audit queries being raised by Controller and Auditor General. In response to this, the Ministry has intensified monitoring and supervision systems on collection, custody, control, programming and expenditure of funds. Corrective measures have been taken on areas that funds have not been accounted for.

The findings of the 10/20 Policy study suggest that the overall impact has been mixed. Utilization of services in the sample facilities generally increased rapidly following the introduction of the policy. However, this growth was not sustained due primarily to non availability of drugs. In the last quarter of 2004 many facilities generally experienced declining utilization although the picture varies by district and according to the type of service and utilization remains, on the whole, above levels in the first quarter of 2004. In the first half of 2005 utilisation of services at health centres appears to have increased and is now roughly back at the levels experienced in July 2004. Utilisation in dispensaries has seen a slight decline in 2005 although, again, it remains above levels before 10/20 was introduced.

There is a consistent theme running through the I-PRSP and the PRSP which is to focus expenditures on rural health services and preventative and promotive health services and reduce the share of the total that curative health services consume. While this focus in not so specific in the ERSWEC, affordability and accessibility of health services for the poor is emphasised. Both policies are wholly consistent. However, the core poverty programmes in health sector are not as focused and are much wider in coverage and need to be reviewed.

The Ministry of Health has a total of ---- ongoing projects mainly including rehabilitation and construction of buildings such as mortuary facilities, non-residential and residential buildings in various hospitals, health centres and dispensaries. At the same time, there are a total of about --- stalled projects whose cost of completion is estimated at Kshs. ---- billion. Most of these projects are being completed through Ministry of Public Works using the KSh 3 billion allocated for stalled projects in 2005/6.

Revised indicators and targets have been developed for the purpose of measuring the budget performance and the Government is commitment to the health sector in the Economic Recovery Strategy (ERS). These indicators form part of the current budget outlook paper

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and will be used to access provided by some Development Partners through budgetary support. The underlying policy principle to attain these targets is the one underlying all policy statements on health: shifting the focus from curative care to preventative care.

Release of money through AIEs to the districts has been a bottleneck to expenditures at the district level. In 2005/6 Treasury allowed funds to be disbursed on pre-financing arrangements. This has ensured that facilities receive an AIE accompanied with a cheque to facilitated programmes implementation and expenditures. It is hoped that in future grants will be issued to health facilities once a legal framework is developed. Currently, the Ministry has developed a position Paper and Guidelines in the flow of funds to the rural health facilities.

On human resources, considerable variation exists. North Eastern Province has 1 doctor per 100,000 populations compared to 4 each in Central and Coast Provinces are significantly higher. Central province has more than double (73) the number of nurses per 100,000 populations compared to North Eastern Province (28). A rational deployment policy is necessary to minimise these disparities in addition to decentralising the personnel functions to the districts. The human assessment for attainment of MDGs work currently being undertaken should form the basis for development of a long term manpower policy.

These achievements set out the basis on the way forward:

Consolidate and strengthen these achievements; Integrate the Annual Operating Plans and the Annual Budget

(recurrent and development); Streamline outputs targets

11 Annexes

Annex 1: Inventory of Stalled Building Construction Projects – D11-Ministry Of

Health

PROJECT NAME %Complete

YearStarte

dLOCATION COST COMPL.

Minor Theatre Children Wd Magutuni H/C 10 1998 Meru South 3,300,000

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Health


YearStarte


Kapsabet Hosp. Renov. 14 1993 Nandi 6,222,000

Kapsabet Hosp. 14 1988 Nandi 26,266,000

Embu PGH HOSP. 15 1984 Embu 250,000,000

Kipeto Disp. 15 1998 Kajiado 1,922,000

Lokitung Hosp. 20 1989 Turkana 63,000,000

Bunyala Hosp.Female Ward 30 1997 Bungoma 2,840,000

Tiva Disp. 38 1996 Kitui 2,000,000

Habasweni Maternity Ward 40 1996 Wajir 1,610,000

Kisii Dist. Hosp. Renov. 41 1991 Kisii 143,364,000

Pala H/C-Completion 45 1992 Homa Bay 1,282,360

Bondo Dist. Hosp Phase 1 45 1990 Siaya 30,000,000

Kaptarakwa H/C 45 1997 Keiyo 600,000

Simotwo H/C 48 1998 Keiyo 8,595,000

Kariko Disp. 50 1997 Nyeri 3,000,000

Nyagande H/C 50 1991 Kisumu 1,739,000

Migori Dist. Hosp.Type E Flat 50 1987 Migori 947,000

Budeta Disp.1No cat F House 50 1992 Busia 730,000

Mariakani HC Service Block 52 1990 KILIFI 2,500,000

Muuti-O-Kiama H/C 60 1998 Meru North 14,465,783

Longisa Dist. Hosp. Phase II 60 1990 Bomet 142,960,000

Msekewa H/C 60 1997 Keiyo 1,224,000

Busembe Disp. 60 1992 Busia 800,000

Agenga Disp 60 1998 Busia 500,000

Iguhu H/C 60 1986 Kakamega 7,547,595

Narok Dist. Hosp. 63 1994 Narok 3,612,000

Bondo Hosp. Fencing Works 65 1997 Bondo 747,000

Nanyuki Dist. Hosp. Renov. 66 1992 Laikipia 24,000,000

Kapcherop H/C 67 1988 Marakwet 3,985,000

Runyenjes H/C Completion of OPD 70 1986 Embu 5,490,000

Pumwani Nyayo Wards 70 1987 Nairobi 66,565,000

OlenguruoneH/C 70 1987 Nakuru 40,690,000

Kibish Disp. 70 1990 Turkana 7,975,434

Kiganjo H/C 73 1997 Nyeri 3,000,000

Staff Houses Dirb Goma Disp. 75 1996 Marsabit 956,000

Nuu H/C Exts 75 1981 Mwingi 8,507,000

Kabarnet MTC 75 1991 Baringo 150,000,000

Sugutar Marmar H/C 75 1990 Samburu 1,522,000

Vihiga Dist. Hosp 75 1989 Vihiga 96,653,600

Upgrading-Gichira H/C 80 1984 Nyeri 19,600,000

Nyamaraga Disp. 80 1995 Migori 262,000

Kagwa Disp.Fencing Work 80 1997 Siaya 247,000

Kapkatet Nyayo Hosp. 80 Buret 210,000,000

Bugina H/C 80 1996 Vihiga 10,583,780

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Health


YearStarte


Kathiani Hosp. Renovation 85 1989 Machakos 1,275,000

Yala Sub-Dist. Hosp. 85 1990 Siaya 5,000,000

Chulaimbo RHTC Staff Houses 86 1997 Kisumu 4,807,000

Isinya H/C Phase II 88 1997 Kajiado 2,622,000

Milo Disp Type F House 88 1996 Bungoma 500,000

Mutito H/C Fencing Work 89 1996 Kitui 500,000

Renovation work Githiga H/C 90 1981 Kiambu 3,870,000

Kunene Disp. Rehab.&Ext. 90 1996 Meru N 400,000

IPD &Service Block-Nyagoro 90 H/Bay

CNV Female&Amenities Lodwar 90 1997 Turkana 540,000

Lodwar Comm. Nurses Training School 90 1988 Turkana 119,000,000

Busia VSCU 90 1991 Busia 10,000,000

Siaya Dist. Hosp.VSCU 94 1991 Siaya 500,000

Uyawi Disp. 94 1990 Siaya 1,804,000

Staff Houses at Kathiani Hosp. 95 1995 Machakos 206,428

Kotulo Disp.&Staff Houses 95 1997 Mandera 766,000

Homa Bay Hosp.Maint. Workshop 95 1991 H/Bay 726,000

Siaya Dist. Hosp.Renov. 96 1996 Siaya 120,000

Katito Disp. 97 1992 Kisumu 400,000

Kangundo Nyayo Wards 98 1993 Machakos 2,881,600

Mbeu RHDC 98 1983 Meru C 3,000,000

Ijara Disp. Completion of Ward 99 1996 Ijara 2,247,000

Kihara H/C 1996 KIAMBU 58,305,000

Muranga D. Hosp. 1997 Muranga 5,746,000

Rehab.&Ext.to Muriranjas Hosp. 1991 Muranga 20,341,200

Kanyanyaini New Disp. 1984 Muranga 2,643,880

Karatina Dist.Hosp.Renov. 1989 Nyeri 5,876,940

Karatina Hosp. Alt to Nyayo Wards 1997 Nyeri 2,000,000

Gichichi H/C High Level Water Tank 1985 Nyeri 1,200,000

Karatu H/C 1986 Thika 55,000,000

Mryachakwe Disp.Bock-Ganze 1997 Kilifi 5,452,540

Completion of Cat.F at Mwanda 1992 Kwale 582,000

Ext. Kitui Dist. Hosp. Kitui 930,000

Marsabit Hosp. Office Block 1996 Marsabit 400,000

Mtito Andei H/C 1988 Makueni 14,741,000

Timau Disp 1987 Meru Central 13,047,000

Mathare Nyayo Hosp. 1989 Nairobi 401,002,000

Medical Training Coll. Staff Houses 1987 H/Bay 40,000

Drugs Store for MOH 1988 Trans Mara 474,000

Cherangany Disp. Ext. 1997 Trans Nzoia 710,000

Webuye Hosp. Repair& Renov. 1996 Bungoma 1,550,000

Bungoma Dist. Hosp. Amenity Wards 1993 Bungoma 2,780,000

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Health


YearStarte


TOTAL 2,122,497,140

Annex __: The list of core poverty Projects/Programmes

1 Health Dev. Project - IDA DARE

11 Sexually Transmitted Infections

2Revolving Drug Fund

12 District Hospitals

3 Supply of Medical equipment

13 Mental Health Services

4 Decentralisation of District Health

14 Spinal Injury Hospitals

5Health Sector Reform

15 Dental Health Services

6 Environmental Health Services

16

Communicable and Vector borne Diseases

7 Rural Health Centres & Dispensaries

17 Nutrition Programme

8 Rehabilitation of District Hospitals

18

Family Planning Maternal & Child Health Care

9 Rehabilitation of Mortuaries

19

Rural Health Centres & Dispensaries

10 National AIDS Control Programme

20

Rural Health Training and Demonstration Centres

12 References

a) Ministry of Health. 2006. “Public Expenditure Review, 2006.” Unpublished. Nairobi.

b) Ministry Of Health: RHF Unit Cost/Cost Sharing Review Study & The Impact Of The 10:20 Policy, 2005

c) Kenyatta National Hospital, Strategic Plan 2005-2010

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d) Kenya Medical Research Institute, Strategic Master Plan 2005-1015. (2005);

e) Ministry Of Health, Report On Human Resource Mapping And Verification Exercise

f) Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH and ORC Macro

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Health & Medicine