KENYA HEALTHCARE FEDERATION COVER PAGE

(Branding to be discussed)

BASELINE STUDY ON HEALTHCARE DELIVERY IN KENYA

December 2009

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TABLE OF CONTENTS EXECUTIVE SUMMARY ............................................................................................................................ ii

1.0 INTRODUCTION ................................................................................................................................. 1

1.1 Overview of the Health System in Kenya ...................................................................................... 1

1.2 Rationale for the Baseline Survey ................................................................................................. 7

2.0 STUDY APPROACH AND METHODOLOGY ......................................................................................... 9

2.1 Approach ....................................................................................................................................... 9

2.2 Methodology ................................................................................................................................. 9

3.0 BASELINE SURVEY FINDINGS ........................................................................................................... 12

3.1 Physical and Human Resources .................................................................................................. 12

3.2 Financial Resources for Healthcare Delivery .............................................................................. 18

3.3 The Kenya Essential Package for Health (KEPH) System ............................................................. 23

3.4 Challenges in Healthcare Delivery System ................................................................................. 28

4.0 CONCLUSIONS ................................................................................................................................. 35

4.1 Organisation of the Healthcare Delivery System ........................................................................ 35

4.2 Reforms in the Health Sector ...................................................................................................... 35

4.3 Distribution of Health Facilities ................................................................................................... 35

4.4 Human Resource ......................................................................................................................... 36

4.5 Health Financing ......................................................................................................................... 36

4.6 KEPH System ............................................................................................................................... 36

4.7 Challenges ................................................................................................................................... 37

5.0 RECOMMENDATIONS...................................................................................................................... 38

5.1 Prioritization of Service Delivery to the Poor and Level I ........................................................... 38

5.2 Improve Efficiency and Effectiveness ......................................................................................... 38

5.3 Rationalisation and Distribution of Facilities .............................................................................. 38

5.4 Rationalisation and Deployment of Human Resource ................................................................ 38

5.5 Capacity Utilisation ..................................................................................................................... 38

5.6 Consultation and Communication .............................................................................................. 38

5.7 Decentralisation and Role of Government ................................................................................. 38

5.8 Alternative Approaches to Healthcare Financing ....................................................................... 39

ANNEXES ............................................................................................................................................... 40

Annex 1: Persons Interviewed .......................................................................................................... 40

Annex 2: Terms of Reference ............................................................................................................ 42

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EXECUTIVE SUMMARY

Introduction

The Government of Kenya controls the health sector through the Ministry of Medical Services and

the Ministry of Public Health and Sanitation. The division of the ministries and their functions run

through from the headquarters down to the field offices. These functions are currently the target of

reform initiatives which have been going on in the health sector since the publication of the Health

Sector Policy Framework in 1994. Also as part of the reforms, the introduction of the Kenya Essential

Package for Health (KEPH) system has enhanced collaboration among the existing essential service

packages and a shift from the previous focus on disease burden to the promotion of healthy

lifestyles of individuals and communities. In this respect, the establishment of the six life-cycle

cohorts and the classification of heath facilities into six levels of service delivery are important

aspects of the KEPH system.

The health sector is pluralistic where health services are provided by many players in the field

including the public sector through the Government of Kenya (GOK) and parastatal organizations,

the private sector comprising the Faith Based Organisations (FBOs) Non-Governmental Organisations

(NGOs) and the Private for-profit facilities. The public sector is the largest provider and financier of

health services and operates health care facilities throughout the country accounting for about 52%

of all facilities.

In the Vision 2030 Master Plan, several structural changes are envisaged to improve and expand the

existing health sector in both public and private spheres to address the challenges. The government

has therefore invited the private sector to join it in the delivery of health care services in line with

the spirit of the Public Private Partnership. However as a major stakeholder in the sector,

representing all private health sector players, the Kenya Healthcare Federation decided to carry out

a baseline study to establish the status of healthcare delivery in both urban and rural areas.

Study Approach and Methodology

The overall objective of the study was to help KHF get accurate information that would help in

designing an alternative healthcare delivery system, including mobilisation of financial resources

which has remained a major challenge. It is expected that the alternative system would be

sustainable, equitable, affordable and accessible to all Kenyans. The approach to this study was

guided by the Terms of Reference provided by the Kenya Healthcare Federation. MICRODE Consult

used participatory approaches of engaging key stakeholders and informants in the collection of the

data and information from the facilities. The facilities covered by the study included representative

samples of five provincial hospitals, five district hospitals, two Health Centres and at least one Faith

Based Organisation/Non-Governmental Organisation and private hospital in each Province.

Key Findings

Physical and Human Resources

The norms and standards for health service delivery have been set for four categories of

infrastructure or physical resources: Buildings comprising medical and non-medical; Equipment

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comprising medical and hospital equipment; Information and Communication Technologies (ICT):

Radio call, telephones, networks; Transport services of various types. Kenya had a total of 5,299

health facilities from level I up to level VI comprising 337 hospitals, 768 health centres and 4,154

dispensaries. All these facilities are equipped with appropriate items to facilitate provision of

services at the respective Levels.

Different Levels have different staffing norms and standards. These constitute the minimum staffing

levels for different staff cadres (e.g. medical specialist, medical officers, nursing officers and clinical

officers) expected to be in place and provide the health services appropriate to the respective

Levels. The study showed that there was overall staff shortage and although the minimum number

could be in-post, this did not mean that it was the right quantity for the workload at the respective

facilities. There was also sub-optimal distribution of staff with respect to type and geographical

locations. Urban locations had favourable distribution compared to rural areas.

Financial Resources

Total Government Expenditure in the period 2005/06 was KShs 401,518,324,607 while Total Health

Expenditure (THE) in the same period was KShs 70,807,957,722. With a population of approximately

37,000,000 then, THE per capita was KShs 1,987 (approximately US$ 27), and THE as a percent of

total Government Expenditure was 5.2%, which is below the Abuja Declaration target of 15%. The

World Health Organisation (WHO) Commission on Macro Economics recommends a per capita

health spending of US$ 34 for financing essential package for health services. Kenya’s healthcare

spending is therefore below the WHO recommendation by about US$ 7 per head. The challenge

therefore remains how to bridge this resource gap, how to allocate the limited resources more

efficiently and how to raise more domestic resources for investing in the health sector. It should be

noted that in 2001/02, government spending on health was 8% of total government expenditure,

5.2% was therefore a reduction.

In 2005/06, out of pocket (OOP) expenditure was the largest contributor to health care financing,

followed by donors and the Government. 35.9% of Total Health Expenditure was met by households,

while 29.3% was paid for by government. Private companies contributed 3.3% while donors

contributed 31.0%.

In terms of managing the funds, the Ministry of Health controlled the largest amount of the funds

available for health care delivery. In 2005/06, Ministry of Health controlled KShs 25,050,931,100

(35%), which was essentially the Ministry of Health Budget allocation, followed by households (OOP)

who controlled 20,611,667,607 (29.3%). In the third place were the NGOs controlling KShs

12,908,526,174 (18%). Private employer and insurance companies were a distant forth controlling

KShs 3,849,460,713 (5%) followed by NHIF in the fifth place with KShs 2,632,570,016 (4%) of the

funds. Ministry of Health allocation has consistently been skewed in favour of secondary and

tertiary health facilities which absorb 70% of health care expenditure at the expense of primary care

units which are the first line of contact with clients and also providing the bulk of health care

services.

KEPH System

The National Health Sector Strategic Plan (NHSSP) II (2005 – 2010) introduced the Kenya Essential

Package for Health (KEPH) to be used as a system of delivering healthcare services. The services are

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to be delivered through six Levels of healthcare including the Community Level. KEPH system

brought about the shift in the approach to health care delivery from focusing on disease to

promotion of healthy lifestyles. KEPH has identified health needs of individuals through six stages of

human life cycle (referred to as cohorts). It recognises that each cohort has unique health needs.

KEPH has also introduced a planning and management process that starts from the community level

and works upwards to national level. The roll out of KEPH was phased. The first phase covering

human life, pregnancy, and delivery and new born up to two weeks was included in the first Annual

Operational Plan 2005/2006. Other phases were to be incorporated in the subsequent AOPs up to

AOP5 covering 2009-2010. However, the levels of awareness of KEPH vary considerably across

service levels and among staff. At Level IV of public facilities, it was established that the Medical

Superintendents and the matrons in charge of maternity were aware of KEPH. The rest of the staff

had heard about KEPH but lacked details of its application. At Level III, the matrons and registered

clinical officers were found to be well versed with KEPH. They however added that the idea had been

sold to them, but resources were not made available for implementation.

Challenges

The challenges facing the healthcare service can be categorized into the three components of the

KEPH system namely: Service delivery; Service delivery resources/inputs; and Service delivery

support systems. The Government has already established norms and standards which are used in

determining whether these challenges are being overcome or not. There have been challenges in the

service delivery ever since the roll-out of the first package. Even up to now, the private sector health

players have not been fully incorporated and therefore their contribution which was envisaged

cannot be quantified.

With respect to resources, infrastructure challenges range from shortage of some critical

infrastructure; lack of maintenance systems to ensure serviceability and functionality of existing

infrastructure; and shortage of skilled personnel to use and maintain the infrastructure. The human

resource has been negatively affected by staff shortage and sub-optimal distribution of available

staff. Regarding availability of commodities, the current practice whereby public facilities are

required to only source their supplies from Kenya Medical Supplies Agency (KEMSA) has created a

monopoly whose effectiveness and efficiency are lacking. KEMSA has adopted the “push” system

and thereby forcing the facilities to receive medicines which they have no immediate use for.

Financing healthcare has remained a challenge to the Government of Kenya for a long time. Key

challenges in financing healthcare include, Large out of pocket expenditure which cannot be

budgeted or programmed for, low investment in health by government, inappropriate allocation of

financial resources within the government health budget, low public awareness on the need for

health insurance.

In the area of service delivery, support systems shortage or lack of qualified staff with management

capacity and ability to motivate staff and offer leadership is a big problem. Effective and efficient

utilization of the systems to achieve the desired results as well as to achieve savings in the use of

resources is also a challenge.

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Conclusion

The splitting of the former Ministry of Health into two ministries of Medical Services and that of

Public Health and Sanitation has brought with it challenges of coordination which are crucial for the

activities of healthcare delivery to be handled seamlessly. The reforms currently underway are

largely confined to the public health sector and yet the private health sector should be part and

parcel of the reforms. The study also showed that the resources have not been equitably distributed.

With respect to Kenya’s annual healthcare spending, it is still below the WHO recommendation by

about US$ 7 per head and the country needs to find appropriate strategies to raise its level of

spending.

However, the challenges facing the healthcare service delivery and the health sector as a whole

cannot just be addressed by merely pumping more money into the sector. The bottlenecks affecting

efficiency, effectiveness and capacity utilisation must first be tackled for increased spending to bring

about desired results.

Key recommendations

The KEPH system has recognised households and communities as the most important Level in reversing the downward trend of health indicators and therefore much more attention should be given to it in terms of resources.

Deployment and utilisation of service delivery support systems will bring about much more effectiveness in achieving results and efficiency in lowering operational unit costs.

It is important to rationalise the distribution of health facilities across the country in terms of population, distance to the nearest facilities as well as the number of ward beds and cots available per region.

There is need for intra-provincial and inter-provincial, including urban-rural, staff redistribution

to bring about a more equitable deployment of available staff.

The recruitment and training of staff to acquire the right skills to enable them perform their

duties is critical to enhancing capacity utilisation.

Information flow to enable the players in the health sector to be aware of the changes taking

place is very important. Clearly established channels of communication are urgently required to

address the information needs of all the stakeholders.

It is necessary for the Government/Ministry of Health to fully decentralise and entrust

healthcare delivery to semi-autonomous public and private sector health facilities. The role of

the Central Government should be confined to policy formulation and regulation of the health

sector.

The move towards universal health coverage should make it mandatory that all Kenyan residents

enrol with at least one health plan. With respect to the poor and indigent, the government must

maintain its social responsibility and roll-out specific health plans for them.

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1.0 INTRODUCTION

1.1 Overview of the Health System in Kenya

1.1.1 Organization of the Ministries in Charge of Health Services

Previously, the provision of healthcare services in the country was the responsibility of the Ministry of Health. However, the formation of the Grand Coalition Government saw the Health Ministry split into two, namely; the Ministry of Medical Services (MoMS) and the Ministry of Public Health and Sanitation (MoPHS). In the new arrangement, the Ministry of Medical Services is directly in charge of all medical facilities falling under the Provincial, District and Sub-District hospitals within the public sector and oversees their equivalents in the private sector. It also oversees the two National/Referral hospitals both of which are semi-autonomous government agencies and teaching medical facilities. The Ministry of Public Health and Sanitation is in charge of Health Centres and Dispensaries. The control of the two ministries is vested in two respective Ministers and their Permanent Secretaries. This division of the control and functions is replicated from the headquarters of the two Ministries and runs through up to the field level.

1.1.2 The Health Care System

Kenya’s current health care systems are anchored on the Health Sector Policy Framework of 1994 and the subsequent National Health Sector Strategic Plans 1999-2004 and 2005-2010. These documents form the foundation of the health sector reform programmes and have guided the implementation of the on-going reforms. The introduction of the Sector Wide Approach (SWAp) to health planning and funding has gone a long way in bringing together all the players in the sector within the spirit of Public Private Partnership. Also as part of the reforms, the introduction of the Kenya Essential Package for Health (KEPH) system has enhanced collaboration among the existing essential service packages and a shift from the previous focus on disease burden to the promotion of healthy lifestyles of individuals and communities. In this respect, the establishment of the six life-cycle cohorts and the classification of heath facilities into six levels of service delivery are important aspects of the KEPH system. Table 1: The public healthcare system comprises of the following levels of facilities:

Level Facility Type

VI Tertiary Hospitals

V Secondary Hospitals

IV Primary Hospitals

III Health Centres, Maternities, Nursing Homes

II Dispensaries, Clinics

Interface

I Community: Villages/Households/Individuals

The health sector is pluralistic in nature, where health services are provided by many players including the public sector through the Government of Kenya (GOK) and parastatal organizations, the private sector comprising the Faith Based Organisations (FBOs), Non-Governmental Organisations (NGOs) and the Private for-profit facilities. The public sector is the largest provider and financier of health services and operates health care facilities throughout the country accounting for about 52% of these facilities.

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National referral and teaching or tertiary hospitals are at the apex of the health care system. In the public sector, these are represented by Kenyatta National Hospital in Nairobi and Moi Teaching and Referral Hospital in Eldoret. In the private sector, the equivalents are Aga Khan University Hospital and Nairobi Hospital. The referrals offer sophisticated diagnostic, therapeutic and rehabilitative services. Provincial or Secondary hospitals offer referral to their respective district hospitals. They oversee the implementation of health services in the districts, maintain quality standards, and control all district relevant activities. Aga Khan Hospitals in Mombasa and Kisumu fall in this level. District and sub-district or primary hospitals offer referrals and guidance to Health Centres. At the same time, they concentrate on their core functions required of their level. With respect to Health Centres, attention is focused on the preventive and curative services, mostly adapted to the local needs. They also offer ambulatory services to the communities. Dispensaries are meant to be the first line of contact with the community. This feature is also shared by the health centres. The dispensaries provide a wide coverage of preventive health services which is critical in the achievement of the health sector reform focus on the individual life style and the community. They also offer basic curative services. The Community level comprising villages, households and individuals is the foundation of service delivery priorities in the new arrangements of the KEPH system of health care delivery. Village Health Committees are expected to be forums through which individuals and households can participate and contribute to their own health and that of the community. The public health service is complemented by for-profit and not-for-profit facilities owned by private entities, NGOs, faith-based organisations and individuals. The facilities include hospitals, maternity homes, and clinics. These comprise over 45% of health facilities in the country.

1.1.3 The Health Service Delivery

The basis of the health care service delivery are the Annual Operational Plans (AOPs) which establish the interventions, programmes, and activities to be undertaken in the course of the year. The principle of bottom-up-approach to planning has given root to the decentralisation of health services to an extent that annual plans are no longer a preserve of headquarters. Facilities and various committees already established right from level I upwards, now prepare their own annual plans to guide them in the health care service delivery. (i) Organization of the Public Health Service Delivery The delivery of health care services in the public sector is vested in various facility management committees, facility management boards and the medical staff employed in those facilities. At the community level, health care interventions and services are guided by the respective AOPs prepared by the Village Health Committees and approved by the Community Health Committees. The plan will generally highlight basic preventive and curative services and education materials. It will be implemented by Community Health Extension Workers, Community Health Workers and Community Own Resource Personnel.

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At the dispensaries and health centres, AOPs will be prepared by the officers in charge and their respective staff. The plans will be approved by the respective Health Management Committees. District structures include the District Health Management Team and District Medical Services Management Team which prepare and implement their respective annual plans and services using their staff. Integrated district annual plans comprise all activities captured in levels I, II, III, and IV. Provincial Health Management Teams and the Provincial Medical Services Management Teams prepare their respective plans for interventions and services. They also consolidate the integrated district plans and the provincial facility plans into integrated provincial plans. At the national level, the health plans and services of the two ministries, parastatals and semi-autonomous health bodies are prepared by their respective planning units for implementation. The national Annual Operational Plan is therefore a consolidation of all provincial plans and the headquarter plans. The national AOP is submitted to the Health sector Coordination Committee for approval. (ii) Organisation of Private Sector Facilities These facilities include faith-based, non-governmental and the private for-profit institutions. They are structured in such a manner as to reflect the philosophy and principles of their owners. Private for-profit facilities are run on profit basis and do not expect to be funded by the government in any manner. The Government and some donors however give some support to faith-based and non-governmental institutions to undertake some specific programmes and services. For example the Government helps some faith-based hospitals by training their staff, seconding personnel and providing some drugs. Furthermore the Government supports Immunisation services in all health facilities irrespective of their ownership. The private sector facilities are expected to operate within the healthcare service delivery standards and protocols set by government and observed by all facilities including those in the public sector. Provincial and District Health Sector Management Boards have supervisory and quality control roles over all private sector facilities in their respective areas of jurisdiction.

1.1.4 Healthcare Facilities

The latest figures by the Ministry of Medical Services for overall healthcare facilities show that there has been substantial increase in these facilities in comparison to the figures which were released by the Ministry of Health in 2005. The tables 1 and 2 below show that hospitals increased by 225, health centres by 77 and dispensaries by 640 more facilities: Table 2: Distribution of Health Facilities by Type and Controlling Agent

Facility Type GOK FBO Private Total

Hospitals 191 76 70 337

Health Centres 465 145 158 768

Dispensaries 2,122 617 1,415 4,154

Total 2,778 838 1,643 5,259

Source: Ministry of Medical Services Facts and Figures 2008

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Table 3: Distribution of Health Facilities and Hospital Beds and Cots by Province Number of health facilities in Kenya and number of hospital beds and cots by province SPA 2004

Number of Institutions Hospital beds and cots

2003 2004 2003 2004

Province Hospitals Health

centres

Dispen-

saries

Total Hospitals Health

centres

Dispen-

saries Total

Number of

beds/cots

Number

per

100,000

population

Number

of

Beds/cots

Number

per

100,000

population

Nairobi 58 54 381 493 71 61 395 527 5,528 21.6 5,528 20.1

Central 65 89 372 526 69 95 392 556 8,542 22.9 8,543 21.2

Nyanza 64 42 334 440 72 37 344 453 8,871 31.4 8,871 30.3

N/Eastern 65 80 692 837 64 79 695 838 8,261 15.4 8,261 16.1

R/Valley 8 12 68 88 13 14 74 101 1,954 14.2 1,954 13.6

Eastern 98 117 333 548 102 118 336 556 12,871 23.2 1,287 26.3

Western 100 161 1,006 1,267 98 196 1,080 1,374 12,832 16.5 12,951 15.4

Coast 68 94 196 358 73 91 198 362 6,992 19.4 6,992 18.0

Total 526 649 3,382 4,557 562 691 3,514 4,767 65,851 19.5 65,971 18.1

Source: Health Management Information System, Ministry of Health, 2005

Table 4 below shows how hospital beds and cots were distributed per 100,000 population by provinces in 2007. National average shows that 53.2% of the population lived within 5 kilometres to the nearest facility. It also shows that national average for the number of beds and cots per 100,000 population was 18.1. Table 4: Distribution of population, beds/cots and nearest distance to facility by Province

Province Population (2007)

% population with less than 5km to nearest facility

# hospital beds and coats per 100,000 population

Nairobi 3,034,400 79.8 20.1

Central 4,556,700 71.4 21.2

Coast 3,228,400 39.7 18.0

Eastern 5,802,100 36.2 26.3

North Eastern 1,313,800 14.3 16.1

Nyanza 5,443,900 56.3 30.3

Rift Valley 9,402,500 52.0 13.6

Western 4,402,200 55.0 15.4

Total 37,183,900 52.3 18.1

Sources: GOK Publications; MOMS Facts & Figures 2008, HMIS 2005

1.1.5 Primary Care Facilities at Levels II and III

These facilities are comprised of Dispensaries and Health Centres. They form the first point of contact between the community and the formal government structure of health facilities. Dispensaries are staffed with Enrolled Community Nurses and Community Health Extension Workers. Health centres have Registered Clinical Officers, Registered Community Health Nurses, Laboratory technicians and Pharmaceutical technologists. The services provided by the staff at the primary facilities cover all cohorts and are commensurate to their capacity as determined by the standards and norms set by the two ministries in charge of the health services. The enrolled nurses at the dispensaries provide antenatal care and treatment for

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simple medical problems during pregnancy and conduct normal deliveries. They also provide outpatient curative care. Health centres provide a wider range of services including basic curative and preventive services for all cohorts, minor surgical services as well as outreach services. They refer difficult cases to district hospitals.

1.1.6 Level IV Facilities

Most District hospitals are Level IV facilities and form primary facilities at the district level for clinical services. They are the first referral hospital for both public and private primary facilities at Levels II and III. Their range of human resource includes: Medical officers, dentists, pharmacists, clinical officers, anaesthetists, nurses, radiographers, dental technologists, laboratory technologists and nutritionists. They provide the following services:

Curative and preventive care and promotion of healthy lifestyles;

Clinical and treatment techniques not available at lower levels;

Laboratory and other diagnostics techniques to support medical, surgical and outpatient activities;

In patient care;

Training and technical supervision to health centres and to act as resource centre;

Specialised services such as obstetrics and gynaenocology, child health, medicine, surgery including anaesthesia;

Twenty four hour service including ambulance and emergency services;

Non clinical support services;

Referral services.

1.1.7 Level V Facilities

All Provincial hospitals (and some district hospitals) are at Level V and form secondary level facilities. They are at the apex of field level medical facilities. They provide more specialized care with skills and competences not available at the district hospitals. Their compliment of human resource include medical specialists such as physicians, obstetricians/gynaecologists, paediatricians, surgeons, psychiatrists, ophthalmologists, ENT specialists, dermatologist, anaesthetist, pathologist, radiologist, orthopaedic surgeon, specialized and general nurses, and medical officers among other support skilled staff. Availability of the above skills has enabled the provincial hospitals to offer the services in the following disciplines:

Medicine;

General surgery and anaesthesia;

Paediatrics;

Obstetrics and Gynaecology;

Dental services;

Psychiatry;

Accident and emergency services;

Ear, nose and throat;

Ophthalmology;

Dermatology;

Intensive Care Unit (ICU) and High Dependency Unit (HDU).

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They also offer the following support services:

Laboratory and diagnostic;

Teaching and training for health care personnel e.g. nurses and medical officer interns;

Supervision and monitoring of district hospitals;

Technical support to district hospitals.

1.1.8 Level VI Facilities

Kenyatta National Hospital and Moi Teaching and Referral Hospital are the only two tertiary public facilities in the country at Level VI category. They are teaching and training centres of excellence and provide more complex health care services requiring sophisticated technology and high skills. They have more concentration of resources and expensive to run. They teach and train health workers at pre-service and in-service levels. The two institutions operate as semi-autonomous government agencies and offer health care services, quality health protocols, research, teaching and training. Health care: The referral institutions are the ultimate facilities for offering complex curative health services for Kenyans and the neighbouring countries. The referrals can thus come from the district, provincial or other private sector facilities or from the health facilities in the neighbouring countries. They also provide preventive services and run several health programmes within the hospitals and as outreach for the communities. They have extra- mural treatment alternatives to hospitalisation such as day surgery, home care, home hospitalisation and outreach. Quality Health Protocols: It is expected that the teaching hospitals constitute the ideal institutions for setting standards in healthcare delivery because of their continuous activities in both academic and practical environments. This should result in high clinical standards and innovative treatment protocols Research: One of the core functions of a university is research, publication and dissemination of research findings. The referral hospitals, apart from their routine activities, are involved in cutting edge research to find solutions to myriad health problems which still defy medical knowledge to this day. Their research goes a long way in formulation of government policies. Teaching and Training: The major reason for the establishment of the referral and teaching hospitals is to teach and train critical high skilled manpower required for the provision of health services in the country. To this end, the two institutions are engaged in the teaching and training of manpower both at graduate and post graduate levels.

1.1.9 Private Sector Facilities

The health facilities outside the government structure include hospitals, maternity, nursing homes and clinics. They provide mostly curative services and are operated by faith-based organizations, non-governmental organizations, private foundations and companies. Faith-based and NGOs are generally not-for-profit institutions. The Ministry of Medical Services provides oversight, supervisory and regulatory roles over them. The government categorises them at levels commensurate to each facility and in tandem with government facilities.

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1.1.10 Voluntary Counselling and Testing Facilities

HIV and AIDS voluntary counselling and testing (VCT) services are provided by several VCT centres which have been set up county-wide. Their management may be by government, NGOs, FBOs or private enterprises.

1.1.11 Health Sector Priorities

Preparation of NHSSP II and the introduction of the KEPH system were done within the overall broader picture of Economic Recovery Strategy 2003-2007 of the NARC government. Key components of the ERS policy as it relates to health sector included:

Introduction of National Social Health Insurance Fund;

Focusing on health investments to benefit the poor;

Increasing cross-sector cooperation between health sector and other socio-economic sectors;

Increasing efficiency and effectiveness through Sector-Wide Approach to planning and funding;

Increasing government funding to the health sector. It was envisaged that fulfilling the above priorities would assist in achieving the following selected targets: Table 5: ERS Targets for the health sector

Indicator Baseline 2003 Target 2008

Development Outcomes

Reduce under 5 mortality rate 115/1000 110

Reduce maternal mortality 590/100,000 560

Reduce HHOOP expenditure 53% 45%

Outputs

Increase GOK expenditure to health 7.2% 12%

Increase health budget allocation to health centres and dispensaries

11% 15%

Increase health budget allocation to drugs 12% 16%

Increase proportion of fully immunized children

74% 85%

Increase contraceptive prevalence rate 38% 45%

Source: NHSSP II, MOMS Fact & Figures

1.2 Rationale for the Baseline Survey

The Kenya Healthcare Federation (KHF) is a member of the Kenya Private Sector Alliance (KEPSA), and is the apex organisation for private healthcare providers in Kenya. KHF pro-actively and constructively engages with the government and other stakeholders to deliver accessible, affordable and quality healthcare through enabling policies that maximise the contribution of private sector. However, the healthcare delivery is currently faced with many challenges and various reforms are currently being implemented or proposed for implementation. Under the Vision 2030 Master Plan, several structural changes are envisaged to improve and expand the existing health sector in both public and private spheres to address the challenges. The government has invited the private sector to join it in the delivery of health care services under the Public Private Partnership. However as a major stakeholder in the sector, KHF decided to carry out a baseline study to establish the status of healthcare delivery in both urban and rural areas.

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1.2.1 Objectives of the Assignment

The overall objective of the assignment was to help KHF get accurate information that would help in designing an alternative healthcare delivery system, including mobilisation of financial resources which has remained a major challenge. It is expected that the alternative system would be sustainable, equitable, affordable and accessible to all Kenyans. Specific objectives of the study are to:

Establish the type and distribution of existing physical resources available for healthcare;

Establish magnitude and sources of funds available for healthcare services;

Identify gaps and challenges in the provision of healthcare;

Identify alternative ways of improving healthcare delivery through Public Private Partnership;

Study, comment, critique and make proposals on the baseline package of health intended to be delivered and known as KEPH (Kenya Essential Package of Health).

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2.0 STUDY APPROACH AND METHODOLOGY

2.1 Approach

The approach to this study was guided by the Terms of Reference provided by the Kenya Healthcare Federation. MICRODE Consult used participatory approaches of engaging key stakeholders and informants in the collection of the data and information from the facilities. The facilities covered by the study included representative samples of five provincial hospitals, five district hospitals, two Health Centres and at least one Faith Based Organisation/Non-Governmental Organisation and private hospital in each Province.

2.2 Methodology

2.2.1 Sampling Strategy and Sample Design

A multi stage sampling technique was used to select facilities for inclusion into the study. Both purposive and random sampling methods were applied. The tools included open ended and semi-structured questions that would allow focused, two-way conversational communication between the consultant and the key respondents. Open ended questions were designed to allow flexibility for probe and detailed discussion.

2.2.2 Purposive Sampling

The study covered different geographical areas with a view to capture different attributes of the climate and population of Kenya and their effect on health. The areas include Coastal, Lake, Rift Valley, Highlands, Arid and Semi Arid and the Capital City. These are presented in Table 6. below.

Table 6: Geographical Coverage Sample

Region Location

Coast Mombasa and environs

Lake Kisumu and Environs

Highlands Embu and Environs

Arid/Semi Arid Machakos and Environs

Rift Valley Nakuru and Environs

Capital City Nairobi

2.2.3 Random Sampling

A mixture of purposive and random sampling was applied in picking the district facilities. This was necessary to ensure that there was a representation of districts within and without the capital/provincial headquarters. However, because there is still some confusion with respect to the new districts in several areas, it was decided that it was safe to consider old districts where clarity was lacking. Random sampling was applied in picking the health centres which are scattered in a radius of 20 kilometres around the district headquarters. This could be changed to include exceptional cases. The same procedure was used in picking the faith- based and private facilities located around the provincial/district headquarters.

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2.2.4 Survey Design

A total of 30 facilities were visited during the survey. These included national/provincial referral, district hospitals, health centres, faith-based/NGO and private facilities. Six facilities were to be visited in each of the five provinces. The distribution and numbers of facilities sampled are indicated in the table below. Table 7: Health Facilities Sampled for the Healthcare Delivery Survey

Province Health Centre

District Hospital

National/Prov. Hospital

Faith Based Private Owned

Nyanza

-Rabuor -Nyahera

Kisumu East

New Nyanza St. Monica’s Hospital, Kisumu

Jalaram Hospital, Kisumu

Eastern -Kaviani -Mitabooni

Machakos Embu Bishop Kioko Catholic Hospital, Machakos

Shalom Hospital, Machakos

Nairobi -Langata -Mathare

Mbagathi Kenyatta St. Mary’s Mission Hospital, Nairobi

Nairobi West Hospital

Coast -Tiwi Rural Training Centre -Diani

Msambweni Coast Mewa Medical Centre, Mombasa

Pandya Memorial Hospital, Mombasa

Rift Valley

-Rongai -Njoro

Molo Rift Valley Mercy Mission Hospital, Koibatek

Valley Hospital, Nakuru

Total 10 5 5 5 5

2.2.5 Development of Instruments, Training and Pre-Testing

The survey instruments were developed by the consultants guided by the objectives of the study and were shared with the representatives of Kenya Healthcare Federation. The instruments developed were a mixture of Questionnaires, Key Informant Interviews and Focus Group Discussions guides. 2.2.5.1 Survey Tools (a) Questionnaires These were developed to collect information covering the following areas:

Resources for Healthcare delivery: The resources enquired included human, physical and infrastructure;

Maternal child healthcare services: The services enquired included antenatal and postnatal care, vaccine logistic system and child healthcare services;

Family Planning services;

Client Satisfaction Survey: to assess service utilization, pricing and overall satisfaction. (b) Focus Group Discussions The tools for focus group discussion were developed to guide discussion on the KEPH system, SWAp initiative, Health Financing and Public Private Partnership. 2.2.5.2 Training and Pre-testing A total of ten research assistants were used in the survey. All were fully qualified diploma and above in reproductive health and currently working in public facilities. Recruitment took place at each provincial headquarters. This was followed by one day training on the questionnaires and field testing of the same.

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2.2.6 Data Collection, Entry and Analysis

2.2.6.1 Data Collection The baseline survey used a mixture of questionnaires, focus group discussions and key informant interviews in all the facilities which were visited. The consultants conducted focus group discussions, key informant interviews with facility management staff in charge of various units and functional areas. They also administered client satisfaction tools on the patients who had been attended to at the facility, received services and were now leaving the facility. Research assistants administered the tools on heads of service areas. To ensure uniform standard and quality control, the survey started in Nairobi where all the consultants worked and conducted all activities together. This also included strict supervision of the research assistants. In all the facilities visited, the consultants and the respective team of research assistants worked together at the same facility to ensure quality control. Each consultant checked all the questionnaires at the end of each day to ensure completeness and correctness of the exercise. Any anomalies detected would be rectified the following day. A total of 30 facilities as indicated in 2.2.4 above were visited. 2.2.6.2 Data Entry and Analysis All the data from the field was transported to the offices of MICRODE CONSULT in Nairobi. The data was entered into the computer for processing using SSPS software and EXCEL. The output was checked and cleaned to facilitate cross tabulation and subsequent analysis and presentation of graphs and tables. This analysis formed the foundation of findings and draft report writing.

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3.0 BASELINE SURVEY FINDINGS

3.1 Physical and Human Resources

3.1.1 Physical Resources

NHSSP II and the KEPH system recognize that for efficient utilization of human resources, appropriate infrastructure is required to ensure that the skills available have the right tools and equipment to do their duties. The norms and standards for health service delivery identify four categories of infrastructure or physical resources:

Buildings: medical and non-medical;

Equipment: medical and hospital equipment;

Information and Communication Technologies (ICT): Radio call, telephones, networks;

Transport services of various types. (i) Buildings As already indicated in table 1, Kenya had a total of 5,299 health facilities from Level II up to Level VI comprising 337 hospitals, 768 health centres and 4,154 dispensaries. Norms and standards have been set for different levels as indicated below: Level III service provision units would require a minimum of 2 acres and would contain:

Medical services provision unit with maternity and inpatient facilities;

Pit latrine;

Staff housing;

Supplies services unit. Level IV service provision units would require a minimum of 5 acres and would contain:

Outpatient service provision unit;

MCP/FP services provision unit;

Inpatient service provision unit;

Radiology unit;

Administration unit;

Pit latrine;

Staff housing;

Supplies services unit. Level V service provision units would require a minimum of 10 acres and would contain all areas listed under level IV plus:

Intensive care unit;

Medical engineering. During the survey, the facilities were checked to see if they had basic items such as client latrines, waiting area protected from sun and rain, basic level of cleanliness, regular water supply, and seasonal or shortage of water. Table 7 below summaries what the survey revealed:

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Table 8: Service and Facility Infrastructure

Facility Percentage of facilities with:

Service comfort Amenities such as Latrine, waiting area, Basic cleanliness

Regular water supply

Seasonal shortage or lack of water

Provincial hospital 100 100 20

District hospital 100 100 40

Health centre 30 100 50

Faith based 100 100 80

Private 100 100 20

Total

Source: This survey

From the table, all the provincial, district, private and faith based health facilities achieved basic service comfort amenities. The health centres achieved 30%. All facilities had regular water supply. However 20% of provincial, 40% of districts and health centres and 20% of private facilities had seasonal shortage or lack of water. (ii) Equipment In terms of norms and standards, all major and small medical and non-medical equipment have been identified for specific levels of health care facility. All units itemised under 3.1.1 (i) above are equipped with appropriate items to facilitate provision of services. Additionally level V should have a medical engineering unit to maintain the equipment. While acquisition of these items may be a one time purchase, their operations and maintenance pose very challenging obligation on the part of facilities administrations. The survey sought to find out how the authorities were handling these items. In this regard, three specific questions were asked to find out if the facility had a programme for routine maintenance and repair of building or infrastructure; major equipment such as generator, refrigerator and sterilisation; and small equipment such as blood pressure cuffs or stethoscopes. When a facility has a programme for routine maintenance it means that the equipment or building is checked regularly even if there is no problem. This could be done by facility staff or contracted outside support. Table 8 below shows how the facilities responded. Table 9: Equipment building maintenance

Facility

Number sampled

Percentage of facilities with:

Preventive Programme for Major equipment

System for repair or replacement of small equipment

System for maintenance and repair of buildings

Provincial hospital 5 100 100 100

District hospital 5 100 100 100

Health centre 10 30 100 50

Faith based 5 60 100 80

Private 5 100 100 100

Total 10

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According to the above, all provincial, districts and private facilities had preventive programmes for major equipment while only 30% and 60% of health centres and faith based respectively had the programmes. All facilities had system for repair or replacement of small equipment. With respect to maintenance and repair of buildings, only 50% and 80% of health centres and faith based respectively had systems in place while all provincial, district and private facilities had established the systems. (iii) Transport, Information and Communication Technology Transport and communication form components for the KEPH system. They support facility needs for mobility, telecommunications and internet to enhance efficiency and effectiveness in client service delivery. The norms and standards require level III to have communication equipment; level IV and V to have communication equipment, vehicles and motor cycle. Consequently, during the survey, facilities sampled were probed to ascertain their status with respect to availability of ambulance/vehicle for emergency transportation for clients; functional computer and a working telephone. Table 10: Transport and ICT Services

Facility Number sampled

Percentage of facilities with:

Ambulance/vehicle For emergency

Functional computer

Working telephone during service delivery

Provincial hospital

5 100 100 100

District hospital

5 100 100 100

Health centre

10 30 80 70

Faith based

5 80 100 100

Private 5 100 100 100

Total 30

Source: This Survey These are basic facilities and it was hoped that all facilities should be fully equipped with them. However as can be seen, only 30% of health centres reported having transport while only 80% and 70% had functional computer and telephone respectively.

3.1.2 Human Resources

In line with KEPH system approach to health service delivery, health facilities have been re-

designated. Instead of being referred to as Provincial General Hospitals, District Hospitals or Health

Centres, the terms Levels V, IV and III respectively are applied. Five Level V facilities were visited

during the baseline survey, namely; Rift Valley, Eastern, Coast and New Nyanza Provincial General

Hospitals. Machakos District Hospital was also indicated to be a level V health facility and has

therefore been categorised so in this report. Different Levels have different staffing

norms/standards, which are the minimum staffing levels for different staff cadres (e.g. medical

specialist, medical officers, nursing officers and clinical officers) expected to be in place.

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(i) Provincial General Hospitals / Level V Health Facilities

Level V facilities are expected to have 24 Medical Specialists with different specialisations: e.g.

Obstetrics and gynaecologists, physicians, surgeons or dermatologists; 15 Medical Officers, 16

Clinical Officers, 220 Nursing Officers, 4 Anaesthetists, 2 Pharmacists, 6 Pharmacist Technologists,

and 7 Laboratory Technicians. The survey revealed two things; that this minimum staffing level was

mostly not met and that there are cases where one facility had more than the minimum

recommended number and yet another facility had less than the recommended minimum number

of that cadre. This is sub-optimal distribution of personnel.

In the Level V facilities (as named above) visited, Medical Specialists that needed to be posted

according to the norms were 120, only 49, that is less than half, were actually on the ground, leaving

a shortfall of 71. On the other hand, Medical Officers required according to the KEPH norms were

75, while actually on the ground there were 91. This means that 24 could have been deployed

elsewhere in the country where the staffing norms were not met.

Severity of staff shortage, especially for nursing officers, increases as one moves downward the

ladder from Level VI to Level III facilities. The Level V facilities visited surpassed staffing norm for

nursing staff by a total of 313, Level IV facilities visited surpassed the norm by a total of 36 while the

10 Health Centres visited had a total shortage of 52 nursing officers. Health service delivery could be

improved by better staff distribution among facilities of different levels of health service.

Pharmacists were generally found to be adequate at Level V facilities, a total of 10 pharmacists were

required in the five facilities according to the norms, while 35 were actually on the ground. This

means 25 pharmacists could have been redeployed in lower level facilities. According to the norms,

there should have been a total of 30 pharmaceutical technologists but there were only 10 on the

ground, therefore a shortage of 20 pharmaceutical technologists. There was a shortage of 9

laboratory technicians as the norm required that the five facilities should have a total of 35

laboratory technicians while on the ground only 26 laboratory technicians were in place. The above

information is summarised in the table below. Negative numbers denote the number of personnel

above the norm/standard requirement.

Table 11: Staffing vis-a-vis Staffing Norms in Level V Facilities Visited

Public Level V Facilities Medical Specialist Medical Officer Clinical Officer Nursing Staff

Norm Actual Rqd Norm Actual Rqd Norm Actual Rqd Norm Actual Rqd

Coast P.G.H 24 10 14 15 21 -6 16 25 -9 220 349 -129

Rift Valley P.G. H. 24 10 14 15 11 4 16 56 -40 220 401 -181

Machakos D. H. 24 15 9 15 27 -12 16 27 -11 220 171 49

Embu P.G. Hospital 24 6 18 15 13 2 16 25 -9 220 231 -11

New Nyanza P.G.H. 24 8 16 15 19 -4 16 22 -6 220 261 -41

Total 120 49 71 75 91 -16 80 155 -75 1100 1413 -313

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Table 11 cont’d...

Public Level V Facilities

Anaesthetist Pharmacist Pharmaceutical Tech Laboratory Technician

Norm Actual Rqd Norm Actual Rqd Norm Actual Rqd Norm Actual Rqd

Coast P.G.H. 4 2 2 2 6 -4 6 3 3 7 4 3

Rift Valley P.G.H 4 1 3 2 11 -9 6 4 2 7 3 4

Machakos D. Hospital

4 1 3 2 6 -4 6 0 6 7 3 4

Embu P.G.H. 4 1 3 2 5 -3 6 1 5 7 10 -3

New Nyanza P.G.H

4 1 3 2 10 -8 6 2 4 7 6 1

Total 20 6 14 10 38 -28 30 10 20 35 26 9

(ii) District Hospitals / Level IV Facilities

Four Level IV public health facilities were visited. According to the norms/standards, these four

facilities should have had a total of 24 Medical Officers, that is, every Level IV facility should have 6

Medical Officers. Only 18 Medical Officers were in place however, leaving a gap of 6 Medical

Officers. There were 71 Clinical Officers in the four facilities compared to the recommended 28 (7

per Level Four facility). This means there were 43 Clinical Officers who could have been deployed to

other deficient Level IV facilities or to lower level facilities. Data for Nursing Staff were only available

for three facilities, which should have had 204 nursing officers but had 240. Of the three facilities,

one rural facility had a shortfall of 12 nursing officers and the other a shortfall of 8 nursing officers.

The excess of 36 is brought about by Mbagathi Level IV facility which had 124 nursing officers as

compared to 68 nursing officers recommended for Level iv.

The four Level IV facilities visited should have had a total of 8 anaesthetists according to the

norms/standards. Each Level IV facility should have at least two anaesthetists. Only one facility had

an anaesthetist and only one, not the recommended two. There was therefore a total shortfall of

seven anaesthetists among the four facilities.

According to the norms/standards, each Level IV facility should have 2 pharmacists, hence the four

facilities should have had 8 pharmacists, but they had a total of 23 pharmacists among them. This

means 15 pharmacists could have been distributed to other facilities deficient of pharmacists. Each

Level IV facility should have at least 2 pharmaceutical technicians. Of the four facilities visited, only

two had 1 pharmaceutical technician each. Instead of the four facilities visited having a total of 8

pharmaceutical technicians; they only had two, leaving six vacant positions for pharmaceutical

technicians.

Each Level IV facility is recommended to have 3 Laboratory Technologists; the four facilities visited

should therefore have had 12 laboratory technologists. The actual number on the ground was 14,

which means they had excess of two according to the norms. It is also recommended that each Level

IV facility should have one nutritionist, a case was found where one facility had 8 nutritionists, and

another had while one had no nutritionist at all. The four facilities visited should have had a total of

4 nutritionists; they had 11 who were sub-optimally distributed. The information above is

summarised in the tables below.

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Table 12: Staffing vis-a-vis Staffing Norms in Level IV Facilities Visited

Public Level IV Facility Medical Officer Clinical Officer Nursing Officers Anaesthetists

Nor Act Rqd Norm Act Rqd Norm Act Rqd Norm Act Rqd

Molo D.H. 6 2 4 7 11 -4 68 56 12 2 0 2

0 0 0 0 0

Msambweni D.H. 6 5 1 7 7 0 68 60 8 2 0 2

Mbagathi D.H. 6 6 0 7 35 -28 68 0 0 2 1 1

Kisumu East D.H. 6 5 1 7 18 -11 68 124 -56 2 0 2

Total 24 18 6 28 71 -43 204 240 -36 8 1 7

Act = Actual; Rqd = Required; Nor = Normal

Table 11: Cont’d...

Public Level

Four Facility

Pharmacist Pharm Tech Laboratory Tech Nutritionist

Nor Act Rqd Nor Act Rqd Nor Act Rqd Nor Act Rqd

Molo D. Hospital

2 3 -1 2 0 2 3 4 -1 1 1 0

Msambweni D. Hospital

2 2 0 2 0 2 3 1 2 1 0 1

Mbagathi D. Hospital

2 15 -13 2 1 1 3 8 -5 1 8 -7

Kisumu East D. Hospital

2 3 -1 2 1 1 3 1 2 1 2 -1

Total 8 23 -15 8 2 6 12 14 -2 4 11 -7

Act = Actual; Rqd = Required; Nor = Normal

On the whole, staff deployment or distribution appears haphazard and does not adhere to the

norms or standards as set out in the KEPH document. It shows that urban areas are favoured and

have better staffing than the rural areas.

(iii) Health Centres/Level III Facilities Ten Level III facilities were visited. According to the norms/standards, the minimum number for key health staff required to deliver minimum package for a health centre serving a catchment area of 30,000 is 2 clinical officers, 14 nursing staff, 1 Community Oral Health Officer, 1 laboratory technician and 1 pharmaceutical technologist. There were mixed results with regards to staffing levels in the ten level III facilities visited- while some met the staffing thresh hold, there were shortfalls in others. Rongai, Mitaaboni and Kaviani health centres which are farthest from the major towns had less than 2 clinical officers which is the minimum number required for a health centre. This also goes for nursing staff, pharmaceutical technologists and laboratory technicians where the minimum norms were not met except for laboratory technician in Rongai. However, Langata and Mathare North health centres in Nairobi were endowed with human resources beyond the norms in the two categories sampled of clinical officers and nursing staff while meeting the norms for pharmaceutical technologists and laboratory technicians. On the other hand, Njoro and Diani health centres represent busy rural commercial centres where the norms have been met except for the nursing staff where the actual number of nursing staff was 9 against the norm of 14 in both cases. Tiwi health centre in the Coast province, being a provincial rural health training centre, had extra functions which made its requirement more than the norms established for ordinary health centres.

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The above information is summarised in the table below: Table 13: Staffing vis-a-vis Staffing Norms in Level III Facilities Visited

Health Centre Clinical Officer Nursing Staff Pharmaceutical Technologist Lab Technician

Nor Act Rqd Nor Act Rqd Nor Act Rqd Nor Act Rqd

Njoro 2 2 0 14 9 5 1 1 0 1 1 0

Rongai 2 1 1 14 8 6 1 0 1 1 1 0

Diani 2 2 0 14 9 5 1 1 0 1 1 0

Mathare North 2 4 -2 14 16 -2 1 0 1 1 0 1

Langata 2 4 -2 14 17 -3 1 0 1 1 0 1

Mitabooni 2 1 1 14 3 11 1 0 1 1 0 1

Kaviani 2 1 1 14 4 10 1 0 1 1 0 1

Nyahera 2 6 -4 14 4 10 1 1 0 1 2 -1

Rabuor 2 2 0 14 4 10 1 0 1 1 0 1

Total 18 23 -5 126 74 52 9 3 6 9 5 4

Tiwi 2 7 -5 14 15 -1 1 1 0 1 0 1

Source: This survey Act = Actual; Rqd = Required, Nor =Normal; Overall staffing in the four categories shows that a redistribution of staff would ensure that norms are achieved in all the categories.

3.2 Financial Resources for Healthcare Delivery

Sustainable provision of health care requires a carefully thought out method for financial resources

mobilisation. In Kenya, a policy framework for financing health care was developed in 1994. This

policy framework identified several methods through which the required financial resources could

be mobilised and these included; taxation, user fees, donors and health insurance. The methods for

financial resources mobilisation should particularly pay attention to the socio-economic status of the

population it intends to serve. There are two sides to service provision; the cost of service delivery

and the ability of the population to pay for it whether as insurance premium or as user fees.

It appears that health has consistently been under financed by the public sector. Per capita health

expenditure ranged from as low as KShs 395.49 (US$ 5.05) in 2000/01, to KShs 488.44 in 2001/02 to

KShs 1,987 (US$ 27) the highest, in 2005/6. Total Government Expenditure has always been below

2% of the GDP as shown in table 13 below:

Table 14: Ministry of Health Expenditures 2001/05 - 2004/051

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

Total Expenditure

12,072 15,234 15,351 11,441 23,611

Per capita KShs 395.49 488.44 481.97 506.05 712.67

Per capita US$ 5.05 6.28 6.29 6.52 9.10

MoH Exp as % of TGE 7.23 9.01 8.33 6.99 7.67

MoH Exp as % of GDP 1.44 1.65 1.49 1.51 1.91

Source: Kenya National Health Accounts 2009, MOMS, MOPHS

1 Adapted from, GoK - Household Health Expenditure Survey Report

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In non-public facilities (private, faith-based and NGOs), health service is financed mainly from the

facility revenues user fees, (OOP), and insurance reimbursements, while in public facilities it is

financed mainly by MoH, OOP and insurance (NHIF) reimbursements.

3.2.1 Health Expenditure

Total Government Expenditure in the period 2005/06 was KShs 401,518,324,6072 while Total Health

Expenditure (THE) in the same period was KShs 70,807,957,7223. With a population of approximately

37,000,000 then, THE per capita was therefore KShs 1,987 (approximately US$ 27), and THE as a

percent of total government expenditure was 5.2%, which is below the Abuja Declaration target4 of

15%. The World Health Organisation (WHO) Commission on Macro Economics recommends a per

capita health spending of US$ 34 for financing essential package for health services. Kenya’s

healthcare spending is therefore below the WHO recommendation by about US$ 7 per head. The

challenge therefore remains how to bridge this resource gap, how to allocate the limited resources

more efficiently and how to raise more domestic resources for investing in the health sector. It

should be noted that in 2001/02, government spending on health was 8% of total government

expenditure, 5.2% was therefore a reduction.

3.2.2 Sources of Funds for the Health Sector

In 2005/06, out of pocket (OOP) expenditure was the largest contributor to health care financing,

followed by donors and the Government. 35.9% of Total Health Expenditure was met by households,

while 29.3% was paid for by the Government. Private companies contributed 3.3% of health care

financing. Financing of Total Health Expenditure in 2005/06 is summarised below:

Public (Government) 29.3% Households 35.9% Private Companies 3.3% Donors 31.0% Local Foundations 0.1% Other (Not specified) 0.4%

100.0%

Figure 1: Contribution as a % of THE (KShs ‘000,000)

The private sector (households, private companies and local

foundations) therefore financed 39.9% of the total health

expenditure.

Key

a. Public

b. Households

c. Private Companies

d. Donors

2Kenya National Health Accounts 2005/06

3 Kenya National Health Accounts 2005/06 4 The African heads of state and government committed to allocate 15% of government expenditure on health.

20

e. Local Foundations

f. Other (Not Specified)

Table 15: Trend in Contribution by Financing Source

2001/02 % 2005/06 % %Change

Public 16,887,646,242 29.6 20,767,151,342 29.3 23.0

Private 1,287,202,570 2.3 2,343,624,368 3.3 82.1

Local Foundations 359,878,761 0.6 64,990,232 0.1 (89.9)

Households 29,180,463,954 51.1 25,402,361,132 35.9 (12.9)

Donor 9,343,893,921 16.4 21,929,224,106 31.0 134.7

Not Specific 38,553,522 0.1 300,606,541 0.4 679.7

57,097,638,970

100.0

70,807,957,721

100.0

Source: Kenya National Health Accounts 2009, MOMS, MOPHS

Table 15 shows that of the three major contributors namely government, private and donors, the

highest increase in contribution of 134% between 2001/02 and 2005/06 was made by donors

followed by private, 82.1% and lastly by government, 23%. The increase of donor funding decreased

household share of contribution from 51.1% to 35.9%. Over the same period, the government

contribution remained more or less the same at 29.3%. The donor funding was mainly from Global

Funds for Aids, TB and Malaria, and the Presidents Emergency Plan for Aids Relief (PEPFAR)

3.2.3 Consumers of Out of Pocket Expenditure

Private for-profit agents are the largest consumers of OOP expenditure (38%) followed by the

government at 30%. Other consumers of OOP are faith-based hospitals who consume 11.1%, private

clinics, 8.6%, pharmacies and chemist shops 4.3%, public health centres and dispensaries 3.9%, faith-

based health centres and dispensaries 3.2%.

3.2.4 Management of Health Funds

Financing agents are those institutions that receive financial resources from whatever source for

healthcare service delivery. When they receive the financial resources, they make decisions, in other

words control how such financial resources are utilised; they decide how, in what proportions and

where the funds are to be allocated. The financing agents include Ministry of Health, Other

Ministries, Parastatals, Private Insurance Companies and households.

Understandably, Ministry of Health controls the largest amount of the funds available for health care

delivery. In 2005/06, Ministry of Health controlled KShs 25,050,931,100 (35%), which was essentially

the Ministry of Health Budget allocation, followed by households (OOP) who controlled

20,611,667,607 (29.3%). In the third place were the NGOs controlling KShs 12,908,526,174 (18%).

Private employer insurance companies were a distant forth controlling KShs 3,849,460,713 (5%)

followed by NHIF in the fifth place with KShs 2,632,570,016 (4%) of the funds. Ministry of Health

allocation has consistently been skewed in favour of secondary and tertiary health facilities which

absorb 70% of health care expenditure at the expense of primary care units which are the first line

21

of contact with clients and also providing the bulk of health care services. Other agents managing

health funds were Office of the President (2%) and parastatal agencies.

Table 16: Agents Managing Health Funds

Financing Agent Funds (KShs) %

Ministry of Health 25,050,931,100 35.4

Office of the President 1,216,785,073 1.7

Local Authorities 408,634,082 0.6

National Hospital Insurance Fund 2,632,570,016 3.7

Parastatals 936,484,747 1.3

Private Employer Insurance 3,849,460,713 5.4

OOP 20,611,667,607 29.1

NGOs 12,908,526,174 18.2

Private Firms 1,378,221,517 1.9

Rest of the World 1,814,676,693 2.6

Total Health Expenditure 70,807,957,722

Source: Kenya National Health Accounts 2009, MOMS, MOPHS

Figure 2: Agents Controlling Health Funds

The private sector,

including the households

and NGOs, controlled

about 57% of the financial

resources in 2005/06 while

the public sector

controlled 43%.

Insurance health spending

is divided into two; NHIF

and Private Health

Insurance. In 2005/06,

total health insurance

spending

amounted to KShs

6,482,030,729- of KShs

2,632,570,016 ( 40.6%)

was attributed to NHIF

while the remaining KShs

3,849,460,713, (59.4%)

was from private health

insurance companies.

22

Table 17: Breakdown of Funds by Provider 200/06

Provider 2005/06 %

Public hospitals 25,349,918,227 35.8

Private for profit hospitals 9,594,537,033 13.6

Not for profit hospitals 3,750,661,195 5.3

Public health centres and dispensaries 6,018,829,327 8.5

NFP health centres & dispensaries 704,932,373 1.0

Private clinics 4,223,592,456 6.0

Private pharmacies 1,824,149,922 2.6

Traditional healers 93,476,597 0.1

Community health workers 497,191,771 0.7

Provider of health programmes 10,777,346,844 15.2

Health administration 7,719,302,797 10.9

Other 254,019,180 0.4

Total 70,807,957,722

Source: Kenya National Health Accounts 2009, MOMS, MOPHS

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3.3 The Kenya Essential Package for Health (KEPH) System

3.3.1 Overview of KEPH

The National Health Sector Strategic Plan (NHSSP) II (2005 – 2010) introduced the Kenya Essential

Package for Health (KEPH) system. KEPH brought about the shift in the approach to health care, from

focusing on disease and curative to preventive and promotion of healthy lifestyles. It further aims to

integrate all health programmes into a single package that focuses its interventions towards

improvement of health at each of the six different phases (stages) of the human development cycle.

KEPH recognises that in each of the six phases, the life-cycle cohorts have unique health needs and

services as identified here-below:

Stage 1: Pregnacy, delivery and new born up to two weeks.

The special needs at this stage are identified as antenatal and postnatal care, care

for the new born and the mother. These are addressed through different relevant

health messages.

Stage 2: Early childhood, 2 weeks to 5 years old.

The special health needs are immunization, deworming, vitamin A supplementation

and protecting the child or keeping the child away from danger.

Stage 3: Late chilhood, 6 to 12 years old.

This cohort needs to be prepared for adolescence therefore health education,

messages on HIV/AIDS, STIs, personal hygiene.

Stage 4: Adolescence, 13 – 24 years old.

The unique health needs are health education on drug abuse, HIV/AIDS, STIs,

premature pregnancy. This stage calls for youth friendly services where the health

service providers appreciate youth and are not judgemental about them.

Stage 5: Adulthood 25 – 59 years old.

The issues to be addressed at this stage include family life issues, work and

unemployment related issues, HIV/AIDs and drug abuse among others.

Stage 6: Elderly 60+.

This is the age burdened by HIV/AIDS orphans, in other words they are the carers.

They are faced with health problems such as diabetes, hypertension and cancers.

KEPH also introduced six levels where the healthcare services will be delivered. These levels have

been identified as follows:

Level I: Community level – the community to be empowered with information and skills .

Level II & III: Dispensaries, clinics, Health Centres and Nursing/Maternity Homes – to provide

mainly promotive and preventive health care with some curative health care.

Level IV – VI: Primary, secondary and tertiary hospitals – to provide mainly curative and

rehabilitative health care.

One of the key innovations of KEPH is the recognition and the introduction of level I services which

are aimed at empowering Kenyan households and communities to take charge of improving their

own health. It envisages building the capacities of households not only to demand services from the

providers, but to know and progressively realise their rights to equitable and good quality health

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care. Henceforth, health planning would introduce a bottom-up approach in which the community

would identify their health intervention needs to be incorporated into district plans and form the

overall national health plan. Performance monitoring would be based on interventions and annual

targets set at various levels.

The systems required to support the KEPH initiative include the following:

Interface between services and community;

District health planning;

Financial management;

Monitoring and evaluation;

Human resources management;

Standards and quality assurance;

Commodity supply chain management;

Maintenance;

Communication systems/ICT.

3.3.2 Gap Analysis of Service Delivery Units

As already indicated, health facilities have been repurposed into service delivery units and reclassiified into Levels. The focus is on function as opposed to physical level. The table 18 below was computed using the established norms to highlight the status of service delivery units for the purpose of guiding the implementation of KEPH. From the table, it can be seen that no service delivery units at the community existed at the start of

KEPH despite the critical role which has been assigned to it. It also shows the overs and under-supply

of delivery units across the provinces. For equity to be achived across the country, the need to

rationalise facilities cannot be overemphasised

Table 18: Service Delivery Units Needed and Available by Level of Care

Province Population Service Delivery Units

Status L1 L2 L3 L4 L5

Central 3,909,782 R 782 391 130 39 4

E 372 89 65

G 19 41 -25 4

Coast 2,801,358 R 560 280 93 28 3

E 334 42 64

G -54 51 -36

Eastern 5,103,110 R 1021 510 170 51 5

E 692 80 65

G -182 90 -14 5

Nairobi 2,563,297 R 513 256 85 26 3

E 381 54 58

G -25 31 -32 3

North Eastern 1,187,767 R 238 119 40 12 1

E 68 12 8

G 51 28 4 1

Nyanza 4,804,078 R 961 480 160 48 5

E 333 117 98

G 147 43 -50 5

Rift Valley 7,902,033 R 1580 790 263 79 8

E 1006 161 100

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G -216 102 -21 8

Western 3,853,936 R 171 385 128 39 4

E 196 94 68

G 189 34 -29 4

National 32,125,361 R 6425 3213 1071 321 32

E 3382 649 526 20

G -169 422 -205 12

Norms and Standards for Health Service Delivery, MOH, 2006

NB: R=Required; E=Existing; G=Gap

3.3.3 Implementation of KEPH

KEPH was to be rolled out in phases during the NHSSP II starting with the first stage of human life:

pregnancy, delivery and new born up to two weeks. The focus was on the provision of ITNs to

pregnant women, antenatal and postnatal care, family planning services, use of skilled birth

attendants and health education. This has been covered reasonably well. Glaring gaps are, however,

in the services addressing the needs of stages 4 and 6 of the human life cycle. Stage 4 is the

adolescence stage; the survey revealed lack of youth friendly services in nearly all facilities visited. It

needs to be emphasised that having HIV/AIDS services, treating STIs and so on do not in themselves

amount to youth friendly services. Youth friendly services include having special time or day for the

youth as well as facilities and staff specific to the youth. Only one facility had clear youth

programmes. Health services for stage 6 of the human life cycle, the elderly, was also also found to

be lacking. Drugs for diabetes and hypertension are very expensive and are not part of the Health

Centre kit from KEMSA. The services for the elderly again, are not limited to making drugs for

hypertension and diabetes available but includes raising awareness on healthy life styles and having

equipment for screeining for these conditions available at appropriate service levels and

encouraging people to go for screening.

3.3.4 Awareness of KEPH

At Level IV of public facilities, it was established that the Medical Superitendents and the matrons in

charge of maternity were most aware of KEPH. The rest of the staff had heard about KEPH and had

some vague understanding but lacked in-depth understanding of it. At Level IV, the matrons and

registered clinical officers were found to be well versed with KEPH. They however added that the

idea had been sold to them, but resources were not made available for implementation, e.g. for

youth friendly services.

In private and faith-based facilities, it was mixed reaction: some had heard about KEPH and even

participated in AOP planning actvities while other had not heard of it.

3.3.5 Performance Review of KEPH and AOPs

An operational performance review of the Annual Operational Plan 3, 2007/2008, was conducted

jointly by the MOPHS and MOMS. Table 19 shows that Tertiary services represented by National and

Provincial services received on-budget allocation of 44.96%, district services 34.30% and health

centres and dispensaries got 20.74% to implement the health services. No allocation was specifically

made to Community at Level I.

In terms of service delivery indicators reflected in table 20, there was a downward trend. In AOP 2,

Percentage of Women of Reproductive Age getting family planning commodities was 43%; women

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attending four antenatal clinics was 52%; delivery by skilled staff in health facility was 37%; and

immunization for less than one year was 80%. Corresponding figures for AOP3 was 37%, 39%, 28%

and 70% respectively.

Table 19: Actual Allocations by Levels and Category for AOP 3 2007/2008 (KES Millions)

Category PE/HRH Comd O&M Grants Infra Vehicl AIA TA Total

LVI - National Services 1,013.6 886.7 809.4 6,457.3 150.4 0 73.7 9,391.3

LV - Provincial Services 2,776.9 258.6 124.1 0 25 0 1 3,185.7

LIV - District Services 8,008.3 731.7 461.3 0 394.4 0 0 9,595.8

LII/III – Rural Health Services

688.1 1,971.5 754.8 1,384.2 999 3.4 - 5,801.3

Sub-total (On-budget) 12,487.0 3,848.6 2,149.7 7,841.5 1,569.0 3.4 74.7 27,974.3

% allocation 44.6 13.8 7.7 28.0 5.6 0.0 0.3

Donors 0.00 1,258.4 956.3 0 12.6 0 0 488.3 2,715.7

Cost sharing 0.00 1,969.0

2,322.0

0 0 0 0 0 4,291.0

Sub-total (off budget donors + Cost sharing)

0.00 3,227.4 3,278.3 0.00 12.60 0.00 0.00 488.30 7,006.7

Grand Total 12,487.0 7,076.0 5,428.0 7,841.5 1,581.6 3.40 74.7 488.3 34,981.0

Source: AOP 3 Performance Report, MOMS, MOPHS

Table 20: AOP3 (2007/08) Performance Review Report: Service Delivery Indicators

Service Indicator NHSSP II Baseline

AOPI AOP2 AOP3 NHSSP II 2010 Target

% WRA getting FP Commodities

10 13 43 37 60

% women attending 4ANCs

54 56 52 39 80

% delivery by skilled staff in HF

42 18 37 28 90

% <1year immunized

58 59 80 70 100

%< getting vitamin A

33 15 34 44 80

TB cases*

108,401 115,234 115,689

ARV Clients*

60,392 120,026 115,689

Malaria* (Mn)

9.15 8.9 8.8

Source: AOP 3 Performance Report, Facts & Figures 2008, Economic Survey 2008.

3.3.6 SWOT Analysis of KEPH

The KEPH system is a major shift in the philosophy, conduct, structure and organisation of the

delivery of healthcare services in Kenya. Against this background, the table below focuses on the

strengths, weaknesses, opportunities and threats which face the system.

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STRENGTHS WEAKNESSES

Anchored on the NHSSP II 2005-2010 Implementation backed by AOPs Governance structures are clear and

distinct Joint roles of Government, Stakeholders,

Donors, FBOs, NGOs, Private Sector fully recognized

Backed by SWAp initiative for one plan, one funding and one M&E

Norms and Standards established to facilitate implementation across board

Financial costing for KEPH and Non-KEPH services done and projected to cover entire plan period, 2005-2010

Identified key health sector indicators to help monitor achievements

Preparation of AOPs of various facilities and districts is still problematic

Coordination of health sector activities as envisaged under SWAp has not been achieved

Harmonization of financial projections components envisaged under KEPH and the traditional allocations with respect to expenditure categories and type has not been achieved

Shortage of trained staff to implement some aspects of KEPH such as planning, budgeting, costing and computation of required resource quantities is a big challenge

The first phase roll-out of KEPH services, MCH/FP, has been to a large extent successful, but subsequent roll-outs were never tied to any particular AOP and therefore not clear to measure achievement

There is not a clear-cut consensus on what constitutes a minimum package of healthcare

OPPORTUNITIES THREATS

Political goodwill to improve and expand health services to all citizens including the poor

Recognition of health sector reforms initiatives in all major policy and planning documents including NHSSP II, Medium Term Plan2008-2012 and Vision 2030.

Collaborative development partners and willing local health sector partners

Slow down in economic growth from a

high of 7% in 2007 to a low of 1.7% Inadequate financial allocation to the

health sector due to budgetary constraints

Failure to meet key health indicators identified in the NHSSP II

Failure to institutionalise the KEPH systems among all the stakeholders

Failure to design and implement equitable healthcare financing mechanism

A synthesis of the SWOT analysis reveals critical issues and challenges affecting all the three

components of the KEPH system. These challenges are addressed in the next section.

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3.4 Challenges in Healthcare Delivery System

The challenges facing the healthcare service can be viewed in three categories namely: Service delivery, Service delivery resources/inputs, and Service delivery support systems. The Government has already established norms and standards which are used in determining

whether these challenges are being overcome or not. Norms and standards are statements of inputs

which are necessary to ensure efficient and effective delivery of health services to the people of

Kenya. Service delivery standards relate to the expectation of each level of care with regard to

service delivery, human and infrastructure resources needed to provide these expectations. Service

delivery norms refer to the quantities of these resource inputs required to effectively, efficiently and

sustainably offer service delivery packages.

3.4.1 Service Delivery

The services to be delivered at each Level of healthcare have been outlined in chapter 1 sections

1.1.5, for primary care facilities Level II and III; 1.1.6 for Levels IV facilities; 1.1.7 for Level V facilities

and 1.1.8 for Level VI facilities.

The roll out of the KEPH systems was to be done in phases during the life of the NSHSSP II. During

the first year, attention was paid to the first two life cycles cohorts namely: pregnancy/new born and

early childhood; and adult age group as indicated in section 3.3 above. The roll out for the Maternal

Child Health and Family Planning for the first cohort has been successful and during the survey all

facilities sampled reported offering the services according to their Levels. However, for adult age

group who needed mainly curative and rehabilitative healthcare, drugs for diabetes and

hypertension are very expensive as they are not part of the KEPH package. The economically

challenged in this group therefore cannot afford the medicine.

As part of service delivery strategy, Annual Operational Plans were established in which all

interventions, services and targets were identified to guide service delivery for the coming year. The

objective was to ensure that all stakeholders in the health sector, both in the public and private

sector, gave their inputs into the plans to form integrated district, provincial and national plans. The

first AOP was prepared to cover 2005/2006 financial year. However there were several challenges of

capacity to undertake such massive assignments throughout the country. Improvements in

subsequent AOPs were made and the current one, AOP 5, for the year 2009/2010 has fully

incorporated a bottoms up approach in which plans from the lower Levels have been integrated with

those of higher Levels to form Integrated district, provincial, departmental and district plans.

However, the private sector has not been involved in all the districts and facilities sampled.

3.4.2 Service Delivery Resources

Resource inputs for the healthcare service delivery have been considered under four categories of

Human capital (staffing), infrastructure, Financing and commodities.

3.4.2.1 Human Resources

The norms and standards for the human resource have been derived taking into account the types

and number of staff needed at each Level. The expected number will then be determined by the

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expected workload based on the activities to be performed at that level, population to be served

and the time each activity takes.

The challenges facing the human resource in the healthcare delivery include:

Overall staff shortage with respect to workload;

Shortage of skilled and specialized staff;

Training opportunities for both pre-service and in-service staff;

Retention of specialist doctors in the service;

Urban and regional staff distribution bias which makes the rural areas and certain regions be disadvantaged in service delivery.

Tables 10, 11 and 12 show the position of staff deployment vis-à-vis the minimum norms established

for the KEPH system of healthcare service delivery in the public sector facilities. In the private sector

facilities sampled, regular staff are only employed at lower cadres like nurses, clinical officers and

medical technologists in various health fields. They are meant to help the health professionals who

are enlisted as visiting consultants. Only some faith based hospitals were found to employ

professional medical staff.

3.4.2.2 Infrastructure

The infrastructure required at different levels is guided by the type of services offered and the

human resources required at the health facility. As with the human resources, the infrastructure

norms refer to the minimum quantities. The four components of infrastructure norms include

buildings, equipment, information, communication technology and transport. These should integrate

harmoniously with other inputs particularly the human resources to ensure efficient, equitable,

effective and sustainable health service delivery.

The challenges facing infrastructure are many and include:

Shortage of some critical infrastructure due to financial limitations;

Lack of maintenance systems to ensure serviceability and functionality of existing infrastructure;

Shortage of skilled personnel to use and maintain the infrastructure.

Table 8 shows the position of maintenance arrangements found in the sampled facilities during the

baseline survey. Health centre facilities had major challenges in having maintenance programmes for

their infrastructure. Availability and serviceability of some basic infrastructure in health centres is

below 100% which has been achieved in district and provincial hospitals. It is worth noting that in

one mission owned facility, equipment which had been donated for Ear, Nose and Throat treatment

and two theatre operating rooms have been lying idle because the facility could no longer afford to

employ qualified doctors to make use of them.

3.4.2.3 Commodities

Availability of commodities comprising medicines and non-medical supplies is a major challenge in all public facilities sampled during the survey. The table below shows the response of clients who were asked if they had received all the medicine prescribed at the facility, among other questions.

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Table 21: Customer satisfaction with service delivery

Facility Number of clients sampled

The percentage of clients who:

Agreed they were given sufficient time to explain their health issue

Received all the medicine prescribed at the facility

Said facility staff were friendly

Were very satisfied

Were satisfied with the services

Provincial hospital 51 92 23.5 96 31.4 63.5

District hospital 52 90 38.5 73 28.8 63.5

Health centre 91 99 69.2 93 56 39.6

Faith based 28 100 85.7 100 60.7 35.7

Private 33 97 72.7 97 39.4 60.4

Source: This Survey

Only 23.5% and 38.5% of customers who visited provincial and district hospitals respectively

received all the medicine at the respective facilities. However, availability of medicine was better in

health centres, faith based and private facilities where 69.2%, 85.7% and 72.7% received the

medicine prescribed.

Some of the challenges in this area include the following:

The current practice whereby public facilities are required to only source their supplies from Kenya Medical Supplies Agency (KEMSA) has created a monopoly whose efficiency and effectiveness are lacking. During interviews in the facilities, the stakeholders lamented that on average they receive between 30-60% of requisitions submitted to KEMSA;

Tying up money allocated for commodities at KEMSA during the financial year. KEMSA has never been able to service requisitions from the health facilities in full making usage of the allocations an academic exercise rather than a reality;

KEMSA has adopted the “push” practice and thereby forcing the facilities to receive medicines which they have no immediate use for;

Records at KEMSA were said not to be very accurate because some facilities were informed that they had exhausted their allocation when on the ground that was not the case.

3.4.2.4 Financial Resources Financing healthcare has remained a challenge to the Government of Kenya for a long time. The main contributors to health expenditure are; households (35.9%), Government (29.3%), donors (31%), private companies (3.3%), local foundations (0.1%) and others (0.4%) according to the 2005/06 figures. Key challenges in financing healthcare include:

Large out of pocket expenditure which cannot be budgeted or programmed for;

Low investment in health by government;

Inappropriate allocation of financial resources within government health budget;

Low public awareness on the need for health insurance;

Inefficient and less effective NHIF. (i) Out of Pocket Expenditure This is mainly the user-fees individuals pay to the health service providers at the time of receiving health service. It is also referred to as household expenditure. It is composed of individuals who have their own money and pay for the health services upon receiving it, organised fund-raisers to raise money for those who are faced with exceptionally high medical bills for specialised treatment (or just bills they can’t afford) and finally, cash given out by individuals to relatives or friends who are in crisis, but need medical services for which they don’t have money. Out of pocket funds are therefore

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not available in such a manner that it can be budgeted for. It is also not the desirable option as falling ill does not always coincide with the availability of funds. (ii) Government Health Expenditure Allocation Over the years, the Government has had difficulty in allocating “adequate” funds to the Ministry of Health. Per capita expenditure on health has been fluctuating but slowly increasing from KShs 395.50 in 2001/2002 to KShs 983.0 in 2007/08. In terms of US dollar, this is from $6.28 to $13.8 respectively, way below the WHO recommended figure of US$ 37 per capita. Ministry of Health expenditure as a percentage of GDP has been equally low as detailed in the table below:

Table 22: Kenya - Total Health Expenditure as % of GDP

S/# Country 2001/02 2002/03 2003/04 200405 2005/06 2006/07 2007/08

1 Kenya 1.7 1.5 1.5 1.6 1.5 1.5 1.7

Source: Government of Kenya, Ministry of Medical Services, Fact and Figures, 2008

This can be compared to health expenditure trends in other countries and the table below

summarises the information. It can be observed from the table that many other countries are

investing in their citizens’ health more than Kenya.

Table 23: Total Health Expenditure as % of GDP for selected countries

S/# Country 1998 1999 2000 2001 2002

1 Ghana 5.7 5.7 5.7 5.6 5.6

2 India 5.2 5.7 6.3 6.1 6.1

3 Mexico 5.4 5.6 5.6 6.0 6.1

4 Nepal 5.1 4.8 4.7 4.9 5.2

5 Indonesia 2.5 2.6 2.8 3.0 3.2

6 Senegal 4.2 4.5 4.7 5.2 6.1

Source: Tough Choices, Investing in Health for Development, Annex C: Health Expenditure trends in selected countries, WHO, 2006

N.A. = Not Available The challenge is not limited to the amount of funds available for health expenditure; allocation of the limited financial resources for different uses within the health sector has not been optimal and remained a challenge. The table below illustrates how funds have been applied for different uses in the Ministry of Health over a period of time.

Table 24: Actual Recurrent (Gross) Expenditure by Economic Category (KShs million)

Details 2002/03 2003/04 2004/05 2005/06 2006/07 % of Total

Salaries and other personnel 7,798 8,101 9,036 10,407 11,347 52.7

Transfers and subsidies 1157 1455 1563 1,635 1,667 7.7

Drugs and medical consumables 1,350 1,716 1,866 2,074 2,388 11.1

Other operations and maintenance 1,257 1,285 1,756 1,481 1,767 8.2

Purchase of plant and equipment 95 15 81 596 527 2.4

Kenyatta National Hospital 2,327 3,409 2,659 2,858 3,100 14.4

Moi Teaching and Referral Hosp 422 458 458 714 747 3.5

Total Recurrent (Gross) 14,405 15,439 17,417 19,765 21,542 100

Source: MOMS Facts and Figures 2008.

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It is important to recognise that in the NHSSP II, the projected cost structure of implementing the KEPH system in the categories of salaries as well as drugs and supplies was given much more weight than the other categories. In the table below, this averages 37% and 31% respectively.

Table 25: Projected Cost of KEPH by Expenditure Categories (KSH Millions)

CATEGORY 2005/06 % 2006/07 % 2007/08 % 2008/09 % 2009/10 %

Salary 23,712 37 27,655 37 30,236 37 33,277 37 37,185 37

Drugs and supplies 20,554 32 23,361 31 25,367 31 27,317 31 30,797 31

Lab tests & other investigations 4,235 7 4,887 7 5,835 7 6,597 7 7,259 7

Bed and meals 5,828 9 6,541 9 6,797 8 7,207 8 7,809 8

Allocated overheads 7,939 12 9,075 12 10,235 12 11,160 13 12,457 12

M&E 2,645 4 3,025 4 3,412 4 3,720 4 4,152 4

Total annual cost 64,913 100 74,544 100 81,882 100 89,278

100 99,659 100

Source: NHSSP II 2005-2010 Further comparison can also be made to the cost structure of one private facility sampled during the survey despite the fact that it is a small entity compared with a whole Ministry. Such a comparison would however not be only interesting but also revealing. Personnel, repairs and maintenance at one of the private hospitals amounted to 45.27 (see the table below) as compared to the Ministry of Health’s 61%. Medicines and other supplies constituted a whopping 43.44% as compared to the ministry’s paltry 11.1%. Plant and equipment at the private hospital was 9.4% of the total expenditure, indicating strong growth and development, whereas in the Ministry this only constituted only 2.4%. Prudent resource allocation remains a challenge to the public health sector. Table 26: Expense Structure for Private Facility

S/# Details Expenditure (KShs) % of Total Budget

1 Personnel, repairs and maintenance 23,700,000 45.27

2 Consultants 1,340,000

3 Medicines 17,000,000 43.44%

4 Other supplies 8,200,000

5 Printing and Stationery 860,000 1.48

6 Workshops and Planning 240,000 0.41

7 Others (Plant & equip, etc) 5,460,000 9.41

Total Expenditure 2009 58,000,000 100.00

Source: This Survey (iii) Health Insurance Health insurance in Kenya has two components; public and private sector insurance. Public sector health insurance is National Hospital Insurance Fund (NHIF) on the other hand private sector health insurance is composed of employer insurance schemes, private individual and community insurance. NHIF contributed KShs 2,632,570,016 to total health expenditure while private insurance contributed KShs 3,849,460,713, making insurance contribution to be KShs 6,482,030,729. Of all the insured people, 83.8% are covered by NHIF, 12% by employer insurance schemes, 7.9% by private individual insurance and 0.6% by community insurance schemes. 0.5% is categorised as others. It is worth noting that whereas NHIF covers 83.8% of all the persons with health insurance, it contributed KShs 2,632,570,016 while private insurance covering 19.9% of people with health insurance contributed KShs 3,849,460,713.

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NHIF was established primarily to provide Kenyans with access to healthcare. It is a mandatory health insurance scheme for all Kenyans in formal employment. It is however a very inefficient and less effective institution as can be seen by the fact that it only contributed 3.7% to total health expenditure in 2005/06. The revenue – benefits payout ratio has remained very low, reportedly at 50%, and this is so when the fund only pays for bed nights. It is faced with many challenges including governance and management. Private health insurance has remained relatively small in Kenya. The fact that NHIF is mandatory for all in formal employment has probably worked against the growth of private health insurance in Kenya.

3.4.2.5 Service Delivery Support Systems.

Quality management system is at the core of acquiring inputs, processing them into final products

and getting the finished products to where they are required to get the job done. In the case of

healthcare service delivery, the systems will help in getting the inputs such as money, human

resources, drugs, commodities and infrastructure in a timely manner. It will also ensure that the

resources are better managed in terms of planning, financial management, monitoring and

evaluation so as to deliver the services required from them.

The challenges facing the healthcare service delivery in this category include the following:

Shortage or lack of the right systems to ensure that their deployment and application can generate the desired results;

Shortage or lack of skilled manpower to enhance utilization of the support systems;

Shortage or lack of qualified staff with management capacity and ability to motivate staff and offer leadership. Management of a system as dynamic as KEPH and which requires a lot of flexibility is uniquely challenging. It was very disappointing that most staff members do not know of the KEPH initiative;

Lack of transparency and accountability to attract confidence of all stakeholders; any new initiative can only succeed if it wins the confidence and ownership of stakeholders. The reforms currently going on in the health sector remain much of a subject for senior officers in the public health sector while leaving out their juniors;

Inadequate capacity for knowledge management to ensure production, preservation and dissemination of knowledge and enhancing of best practices;

Enhancing governance and management structures to ensure that all actors, partners and stakeholders recognize each others’ role and are prepared to work harmoniously for the common good is a key challenge. During the focus group discussions, it clearly emerged that organizations operating facilities run by private and FBO have not been incorporated into various forums where health plans are being articulated. All of them claimed they are never invited into such meetings particularly those dealing with annual operational plan activities. Indeed, even at the national level, KHF indicated that they are not represented at the Health Sector Coordinating Committee where annual operational plans are approved;

Communication and information flow is a problem both within the public sector and between the public sector and the private sector. Within the public sector, this could be seen during the focus group discussions when most members revealed that they had never seen the documents associated with KEPH and its implementation. Between the public facilities and the private ones, the challenge is to keep the private sector informed of changes occurring in the health sector which require their participation.

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Records and data management capacity at the facilities are not up to the required standards. In many facilities, the survey was hampered by lack of readily available records. It was obvious that the capacity of the current staff to collect, collate, analyze and manage data was inadequate.

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4.0 CONCLUSION

4.1 Organisation of the Healthcare Delivery System

The splitting of the Ministry of Health into two ministries of Medical Services and that of Public

Health and Sanitation has brought with it challenges of coordination which are crucial for the

activities of healthcare delivery to be handled seamlessly. The Health Centres in particular have dual

responsibilities to the two ministries. For administrative control, they fall directly under the Ministry

of Public Health and Sanitation and in the referral system they have a reporting regime to the

Ministry of Medical Services which is in charge of district and provincial hospitals. This arrangement

requires extreme understanding of the players on the ground because any small misunderstanding

can seriously affect the working arrangements particularly in the referral system and even

information and data flow.

4.2 Reforms in the Health Sector

The reforms which have been going on since the 1994 when the Kenya Health Policy Framework

document was published have introduced a paradigm shift from what the players have previously

been used to. It is obvious that the understanding of these changes and the strategies already put in

place to implement them have not been communicated or explained to all health workers. In the

public sector where these changes originate and domiciled, majority of staff members in the field

are just not on board at all. For example, when the staff are involved in preparing annual operational

plans and setting targets they are not aware that what they are doing is part of a bigger picture of

the reforms embracing the KEPH system and its implementation.

The private health sector which is also part and parcel of the healthcare delivery system is not a full

participant in the reform process. Although they are supposed to participate in meetings which are

arranged to help in the implementation of the reform process, on the ground, they do not attend

such meetings, many times because they are not aware. They are therefore not on board with the

new changes taking place. The survey found no evidence of any private facility with an annual

operational plan prepared in the format suggested by the KEPH requirement.

4.3 Distribution of Health Facilities

The total number of health facilities owned by all the players in the private institutions including

faith based, non-governmental and the private organizations is about 48% in comparison to 52%

owned by the public sector. In terms of distribution, Nairobi which had a population estimated at

3,034,000 in 2007 had the highest population of facilities at 79.8% with less than 5 kilometres to the

nearest facility, while North Eastern with a population of 1,313,800 had the least population of

14.3% within 5 kilometre of a facility. Thus Nairobi residents would spend less money and time to

reach a facility compared to North Eastern and the rest of the provinces.

Nyanza, with a population of 5,443,900, had the highest number of wards beds and cots of 30.3 per

100,000 population compared to Rift Valley with a population of 9,402,000 and 18.1 beds and cots

per 100,000 population. Thus the probability to find a space in the health facility for an inpatient in

Nyanza is the highest in the country compared to all the provinces including Rift Valley.

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4.4 Human Resource

Norms and standards have been established for minimum staffing at various levels of public health

facilities. The survey revealed that overall there was a shortage of staff in most facilities as

computed by the facilities. While some facilities may have met the minimum threshold, this did not

mean that they had the desired number in relation to the workload as dictated by the catchment

population. Some facilities however did not even meet the minimum threshold. For example, in the

sampled Level V facilities, a total of 120 medical specialists were required but only 49 were actually

in post; while a total of 75 medical officers were required yet 91 were in post. This means that 24

could have been deployed elsewhere in the country where the staffing norms were not met. It was

noted that shortage of staff increased at the lower facilities. For example staffing for nurses at Level

IV facilities surpassed the norms by 313, Level IV by 33 while the health centres had a shortage of 52.

4.5 Health Financing

From the recommendations of the Abuja declaration of 2001 and the World Health Organisation, the

conclusion to be drawn is that health sector has been under-funded in Kenya. Total Government

Expenditure in the period 2005/06 was KShs 401,518,324,607 while Total Health Expenditure (THE)

in the same period was KShs 70,807,957,722. With a population of approximately 37,000,000 then,

THE per capita was therefore KShs 1,987 (approximately US$ 27), and THE as a percent of total

government expenditure was 5.2%, which is below the Abuja Declaration target of 15%. The World

Health Organisation (WHO) Commission on Macro Economics recommends a per capita health

spending of US$ 34 for financing essential package for health services. Kenya’s healthcare spending

is therefore below the WHO recommendation by about US$ 7 per head. The challenge therefore

remains how to bridge this resource gap, how to allocate the limited resources more appropriately

among expenditure categories and how to raise more domestic resources for investing in the health

sector. It should be noted that in 2001/02, government spending on health was 8% of Total

Government Expenditure, 5.2% was therefore a reduction.

Sources of financing the health sector include the government (representing the public sector

budget allocation), households, private sector, donors, local foundations and others. According to

the National Health Accounts, households paid the biggest proportion of the health budget at 39%

compared to the government portion of 29.3% and the private companies’ portion of 3.3%. The

large proportion of household payment is unpredictable and should be reduced to the minimum or

eliminated altogether.

Insurance health spending is divided into two; NHIF and Private Health Insurance. In 2005/06, total

health insurance spending amounted to KShs 6,482,030,729 of which KShs 2,632,570,016 (40.6%)

was attributed to NHIF while the remaining KShs 3,849,460,713, (59.4%) was from private health

insurance companies. As can be seen from the role it is already playing, private health insurance has

the potential to contribute more to healthcare spending if the playing ground were made more even

(contributions to NHIF are mandatory).

4.6 KEPH System

Introduction of the KEPH system articulated healthcare delivery by reclassifying the health facilities

into six Levels and their functions. Each facility at every level was defined by the catchment

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population, the range of services to be offered; the resources or inputs required; and the support

systems required to help in the management of the entire system. When KEPH recognized the

Community as the basic unit and the first level of healthcare delivery and formalized the

organizational structure to mobilize the community to take charge of their basic health needs, it

brought a paradigm shift from the previous scenario. Henceforth, the principle of meeting basic

health needs and rights of individuals equitably was enshrined in the guiding principles of healthcare

service delivery of the government of Kenya. However, the implementation of KEPH system is faced

with considerable challenges.

4.7 Challenges

The reform initiatives currently underway in the health sector and their implementation face

considerable challenges which must be addressed for the results to be positively felt by the

consumers who are the real beneficiaries. The challenges have been categorized into three areas. In

the first instance there are those challenges which affect the service delivery. These include the

phased roll-out of the range of services which started with maternal child health and family planning

which has registered good success. Other phases have not recorded much success.

Secondly, there are challenges associated with service delivery resources or inputs required to be

used in the delivery of the services. Thirdly, there are challenges facing the service delivery support

systems necessary to help in the management of the activities in the service delivery and the

utilisation of the resources.

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5.0 RECOMMENDATIONS

5.1 Prioritization of Service Delivery to the Poor and Level I

The KEPH system has recognised households and communities as the most important Level in reversing the downward trend of health indicators. With a population of 46% living below the poverty line (50% rural and 33% urban), it is important that more attention in terms of organisation and resources should be given to the Level I service delivery units than what is given at present. Health investment in this area has a huge knock-on effect on poverty and economic development and thereby empowering communities to meet their basic needs including health insurance.

5.2 Improve Efficiency and Effectiveness

Service delivery is about achieving results and meeting targets set in the Annual Operational Plans of various health facilities. It is also about meeting these targets through eliminating waste and realising savings in the use of resources such as time, money and effort so as to bring down unit cost of interventions. Deployment and utilisation of service delivery support systems will bring about effectiveness and efficiency in the implementation of the KEPH system.

5.3 Rationalisation and Distribution of Facilities

The Ministries of Medical Services and Public Health and Sanitation should consider rationalising the distribution of health facilities across the country in terms of population, distance to the nearest facilities and the number of ward beds and cots available per region.

5.4 Rationalisation and Deployment of Human Resource

Increased investment in the health sector should include hiring more staff and staffing norms should

be adhered to as much as possible. Staffing in Level III and II (Health Centres and Dispensaries)

should particularly be paid special attention if access to healthcare is to be achieved. There is need

for intra-provincial and inter-provincial including urban-rural staff redistribution to bring about a

more equitable deployment of available staff than what is the case now.

5.5 Capacity Utilisation

Training of staff to acquire the right skills to enable them perform their duties is critical to enhance

capacity utilisation. This is essential in addressing the challenge of idle capacity occasioned by

mismatch between the resources available and the capacity to utilise the resources for optimal

productivity.

5.6 Consultation and Communication

Any policy changes should be properly and adequately articulated and information passed down to all facility levels as well as stakeholders in the public and private sectors. Consideration for any additional resource requirement for such changes need to be discussed and/or made available to the facilities as appropriate. Facilities should be encouraged to bring such policy changes to the attention of all their staff.

5.7 Decentralisation and Role of Government

Organisation and Management structure which was designed and currently being implemented to

deliver the KEPH system has created a very fertile ground for full blown decentralisation of the

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health care delivery system. It is therefore appropriate for the Government/Ministry of Health to

entrust healthcare delivery to semi-autonomous public and private sector health facilities. The role

of the Central Government should be confined to policy formulation and regulation of the health

sector

5.8 Alternative Approaches to Healthcare Financing

Healthcare financing is currently a subject under very intensive discussion both in the government

and private sector. Already the Government has put forward a position paper on the way forward.

However, in this document we put forward suggestions which could be taken on board, reflecting

the general consensus in the private sector.

5.8.1 Government should maintain its social responsibilty to the poor with respect to healthcare

financing. It should concentrate on the 46%, comprising about 11 million indigents and 9 million

poor, leaving below the poverty line.

5.8.2 Government should allow the introduction of multiple health plans to be administered by

several health insurers/purchasers.

5.8.3 The move towards universal health coverage should make it mandatory that all Kenyan

residents enrol with at least one health plan.

5.8.4 There is need to define and cost the a minimum health package to which each and every

Kenyan resident is etitled. Those who require additional healthcare should pay for it.

5.8.5 A body charged with regulating and costing of health benefits such as Health Benefits

Regulatory Authority should be established.

5.8.6 Repurpose existing consumption tax to plug the whole in the financing gap which may be

occasioned by meeting social responsibilty for the poor.

5.8.7 Expenditure projections for the KEPH system were made on the basis of allocating an average

of 37% and 31% for salaries, drugs and supplies respectively. It is recommended that this balance be

achieved as a way of repurposing expenditure allocations in the health sector budget.

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ANNEXES

Annex 1: Persons Interviewed

Name Position Organisation Location

1. Dr. Jotham N. Micheni Chief Executive Officer, Kenyatta National Hospital

Nairobi

2. Mr. Kennedy Auka Deputy Director, Finance and Administration

Kenyatta National Hospital

3. Dr. Esther Getambu Provincial Director of Medical Services

MoMS Nairobi

4. Dr. Samuel Ocholla Provincial Director of Public Health and Sanitation

MoPHS Nairobi

5. Dr. Kioko Provincial Director of Public Health and Sanitation

MoPHS Kisumu

6. Dr. Andrew Suleh Medical Superintendent and Chair, Kenya Medical Association

MoMS Nairobi

7. Dr. Ojwang Lusi Provincial Director of Medical Services

MoMS Kisumu

8. Mrs Jane Raburu District Public Health Nurse MoPHS Kisumu East

9. Dr. Thiong’o Provincial Director of Medical Services

MoMS Embu

10. Dr. Robert Ayisi City Medical Officer of Health City Council of Nairobi

Nairobi,

11. Dr. Mwendwa Medical Superintendent MoMS Machakos

12. Mr. Elkana N. Onguti Head, Policy and Planning Division

MoMS Nairobi

13. Dr. Walter P. Konya St. Mary’s Hospital Nairobi,

14. Fr. Bahati St. Mary’s Hospital Nairobi, St. Mary’s Hospital

15. Dr. Irene Muchoki MoPHS Nairobi, Langata H. C.

16. Lydia Kiplagat Matron in Charge MoPHS Nairobi, Langata H. C.

17. Mrs Phoebe Ageng’o Matron in Charge Jalaram Nursing Home

Kisumu

18. Mr. Charles K’Otung’ Administrator Jalaram Nursing Home

Kisumu

19. Mr. Moseti RCO MoPHS Rabuor H. C.

20. Mrs Akelo Matron in Charge MoMS Kisumu East, District Hospital

21. Mr. Paul Omwandho Health Administrative Officer MoMS Kisumu East, District Hospital

22. Dr. Muli Medical Superintendent MoMS Embu,

23. Angela Katundu RCO in Charge MoPHS Kaviani

24. Mr. Nicholas Muindi Nursing Officer MoPHS Kaviani

25. Faith Kavata RCO in Charge MoPHS Mitaboni

26. Damaris Musyoka Nursing Officer MoPHS Mitaboni

27. Regina Muthusi Nursing Officer MoPHS Machakos District Hospital

28. Mrs Stella Mwongela Matron In Charge MoMS Machakos, District Hospital

29. Ms Margaret Wanjohi Nursing Officer Bishop Kioko Machakos

30. Mrs Gladys Owira Administrator/Matron in Charge

St. Monica Hospital Kisumu

31. Mr. John Mwangi Nursing Officer MoPHS Nyahera, H. C.

32. Ms Esther Nyamusi RCO in Charge MoPHS Nyahera, H. C.

33. Ms Bwire Nursing Officer MoPHS Rabuor H. C.

34. Mr. Anthony Momanyi Nursing Officer MoPHS St. Monica Hospital

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35. Mrs Anne Mutunga District Public Health Nurse MoPHS Machakos

36. Mrs Ludmila Shitakha Planning Manager Kenyatta National Hospital

Nairobi

37. Fr. Daniel Muvaa Manager Bishop Kioko Machakos

38. Mr. Amit Singh Chief Financial Officer Nairobi West Hospital Nairobi

39. Dr. G. W. Mugenya Med Sup P G H -Nakuru Nakuru

40. Mr. J. Ochula Nursing Officer P G H -Nakuru Nakuru

41. Ms R. Lumbanga Nursing Officer P G H -Nakuru Nakuru

42. Ms C. Wanjiku Nursing Officer P G H -Nakuru Nakuru

43. Mr. D. Kivui Nursing Officer P G H -Nakuru Nakuru

44 Mr. E. Muhavi Nursing Officer P G H -Nakuru Nakuru

45 Dr. D .G. Kariuki Med Sup Molo D. Hospital Molo

46 Mr D .M Kimani Occ. Therapist Molo D. Hospital Molo

47 Mr M. Mwangi C officer Molo D. Hospital Molo

48 Mr M. Mutura Radiographen Molo D. Hospital Molo

49 Mr J. Tallam Engineer Molo D. Hospital Molo

50 Mr F. Kenarja Physiotherapist Molo D. Hospital Molo

51 Mr J. Nyangan Nutrtionist Molo D. Hospital Molo

52 Mr A. Kihangare Pharmacist Molo D. Hospital Molo

53 Mr G. Ogendi S N O Molo D. Hospital Molo

54 Ms Ziporah Nursing Officer Molo D. Hospital Molo

55 Ms G. Gikonyo Nursing Officer Molo D. Hospital Molo

56 Mr Rotich Bargoye Nursing Officer Rongai H.Centre Rongai

57 Ms C. Chepkirui Nursing Officer Rongai H. Centre Rongai

58 Ms T. Kamau Nursing Officer Njoro H. Centre Njoro

59 Ms F. Ngome Nursing Officer Njoro H. Centre Njoro

60 Mr Jacob Chelimo Nursing Officer Njoro H. Centre Njoro

61. Mr G. S. Mwaura H A O Mercy Mission Hospital

62. Mr G. Chemutai Nursing Officer Mercy Mission Hospital

63. Ms M. Njuguna Nursing Officer Mercy Mission Hospital

64. Ms L. Obwanga Matron in Charge Valley Hospital

65. Mr John Kabochi Nursing Officer Valley Hospital

66. Ms M Kamau Nursing Officer Valley Hospital

67. Dr. D. Maganga Chief Admin/ Med Sup C. P. G. Hospital Mombasa

68. Dr. D. I .Mwangi Deputy Chief Admin C. P. G. Hospital Mombasa

69. Dr. P. Kambu Matron C. P. G. Hospital Mombasa

70. Dr. Mwangi Matron C. P .G. Hospital Mombasa

71. Dr. Charity Matron C. P .G. Hospital Mombasa

72. Mr H .M. Nyamu H R M & I R Pandya Memorial Hospital

Mombasa

73. Ms Martha Nursing Officer Pandya Memorial Hospital

Mombasa

74. Ms Mwachunya Nursing Officer Pandya Memorial Hospital

Mombasa

75. Mr Mose Health Administrative Officer Msabweni Dist Hospital

Msabweni

76. Ms Mwajuwa Nursing Officer Msabweni Dist Hospital

Msabweni

77. Ms Jane Nursing Officer Msabweni Dist Hospital

Msabweni

78. Ms Binti Nursing Officer Msabweni Dist Hospital

Msabweni

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79. Mr. Mutinda Kisingu Officer In change PR H C - TIWI Msabweni

80. Ms Nduati Nursing Officer PR H C - TIWI Msabweni

81. Mr. S.Chepkiwok RCO in Charge Diani Health Centre Msabweni

82. Ms Anna Nursing Officer Diani Health Centre Msabweni

83. Ms Mishi Nursing Officer Diani Health Centre Msabweni

84. Mr. Mohammed Harsan H A O Mewa Medical Centre Mombasa

85. Dr. Mohammed Kombo C E O Mewa Medical Centre Mombasa

86. Dr. Mohammed Ali Chief Accountant Mewa Medical Centre Mombasa

87. Ms Fatuma Nursing Officer Mewa Medical Centre Mombasa

Annex 2: Terms of Reference

1. Background

Under the auspices of Kenya Private Sector Alliance (KEPSA), the Kenya Healthcare Federation (KHF)

is the apex organisation for private healthcare providers in Kenya. KHF proactively and constructively

engages with the government and other stakeholders to deliver accessible, affordable, quality and

sustainable healthcare through enabling policies that maximise the contribution of private sector.

However the healthcare is currently faced with many challenges. Under the Vision 2030 Master Plan

several structural changes are envisaged to improve and expand the existing health sector in both

public and private spheres to address the challenges.

As a major stakeholder in the sector, KHF would like to carryout a baseline study to establish the

status of healthcare delivery in both urban and rural areas. This will help in designing an alternative

approach for health service delivery including mobilisation of funds. KHF is in the process of

identifying a consultancy firm to carry the study.

2. Objectives of the consultancy

The overall objective of the assignment is to help KHF design an alternative healthcare delivery

system which is sustainable, affordable and accessible to all Kenyans.

Specific objectives of the study are to:

a) Establish the type and distribution of existing physical resources available for healthcare b) Establish magnitude and sources of funds available for healthcare services c) Identify gaps and challenges in the provision healthcare d) Identify alternative ways of improving healthcare delivery through Public Private Partnership. e) Study, comment, critique and make proposals on the baseline package of health intended to be

delivered and known as KEPH (Kenya Essential Package for Health). 3. Scope of Work

The study is to cover at least five Provincial and one district hospital within the province and two

Health Centres. Specific tasks will include, although will not be limited to:

a) Review relevant documents for health sector b) Identify facilities and stakeholders to be visited c) Prepare tools for gathering data and information from the facilities visited d) Carry out field work in the selected provinces and districts

43

e) Collate, analyse, summarise and interpret the data f) Prepare findings and recommendations The selection of the provinces, districts and Health Centre should reflect a representative sample

4. Outputs / Deliverables

The main output of the assignment will be the baseline study report. The contents of the report will

include:

a) A baseline information indicating findings on physical facilities, equipment, human resource, funding and facilities ownership;

b) An analysis of the findings, the impact and implications on healthcare delivery c) Recommendations on the way forward

5. Timeframe

The assignment should begin in the first half of November 2008. It is expected that the assignment

will be finalised within 90 calendar days from the date of start.

6. Expertise Required

Demonstrated understanding of healthcare delivery systems;

Experience in carrying out baseline surveys, especially in the health sector;

Experience in strategic planning;

The firm and/or nominated consultants must have carried out a similar baseline study and planning

over the last five years.