Kenya’s Health Sector Budget: How Aligned is it to the Child National Health Priorities?...
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Kenya’s Health Sector Budget: How Aligned is it to the Child National Health Priorities? International Society for Child Indicator’s (ISCI) Conference,
Kenyas Health Sector Budget: How Aligned is it to the Child
National Health Priorities? International Society for Child
Indicators (ISCI) Conference, held in York, UK 27 th 29 th July
2011 Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K.
Ndenge, The opinions expressed are the personal thoughts of the
contributors and do not necessarily reflect the policies or views
of the institutions or any other organization involved and named in
this paper 1 Government of Kenya
Slide 2
Outline Introduction Data and Methods Results Discussions By
Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K.
Ndenge, 2
Slide 3
INTRODUCTION By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba
and Godfrey K. Ndenge, 3
Slide 4
Kenyas Profile Location: East Africa; Borders Somalia and
Indian Ocean in the east; Ethiopia and South Sudan in the North;
Uganda in the West and Tanzania in the South. Population: 38.6
million (males 49.8% and females 50.2%). Approximately half of the
population is poor. By Albert Mwenda, Robert Peter Ndugwa, Isa
Achoba and Godfrey K. Ndenge, 4
Slide 5
In 2009/10, most health indicators for children and women were
off the set sector targets A. K. Mwenda5 Health IndicatorUnit of
Measure Sector Target 2009/10 Achievement -2009/10 Under 5
Mortality rate Per 1,000 live births 5574 Maternal Mortality
ratePer 100,000254488 Skilled attendant at Birth Percent (%)6443
Immunization Coverage % of children under 1 year fully immunized
8577 Access to HIV healthcare services % of patient on ARVs 6056.2
Source: Republic of Kenya (RoK), 2011. Second Annual Progress
Report on the Implementation of the First Medium Term Plan (2008
2012), Nairobi: Government of Kenya.
Slide 6
Preventable diseases/conditions continue to be the leading
causes of In-Patient Mortality for under fives in Kenya By Albert
Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndenge, 6
Source: Health Management Information System, 2008 as cited in RoK,
2011b. Health Situation Trends and Distribution 1994 2010 and
Projections for 2011 - 2030. Nairobi: MoMS and MoPHS.
Slide 7
Situational Analysis of Children and Women Health Nutrition:
National prevalence rates of stunting, wasting and underweight
children have remained almost stagnant at approximately 35%, 7% and
20% respectively. The national averages of children nutritional
status also mask regional disparities. Sanitation Most households
(53.7% of the poor households and 40.2% of the non-poor households)
in Kenya use unsafe drinking water and live in environments
characterised by poor sanitation. Among the poor households only 1
in 5 access piped water, compared to 2 in 5 non-poor households.
Diarrhoea and intestinal worms infestation that are linked to
unsafe water, together accounted for approximately 10% of the
outpatient visits in 2008 (RoK, KDHS 2009). A. K. Mwenda7
Slide 8
Situational Analysis of Child and Women Health Immunisation
Although, national immunisation coverage has increased from 57% in
2003 to 77% in 2008/09, poor health seeking behaviour and long
distances to health facilities have hindered the equitable coverage
of immunisation programmes. As a result, the country has not
attained the set target of 85%. National average mask significant
regional disparities. Reproductive health care Although the country
has a high coverage of Antenatal Care (92%), only 44 percent of the
deliveries are conducted under skilled care, either by a nurse,
midwife or a doctor. By Albert Mwenda, Robert Peter Ndugwa, Isa
Achoba and Godfrey K. Ndenge, 8
Slide 9
DATA AND METHODS By Albert Mwenda, Robert Peter Ndugwa, Isa
Achoba and Godfrey K. Ndenge, 9
Slide 10
Data and Methods Qualitative and quantitative data Data
verified by government officials to confirm accuracy and solicit
explanation Assessment criteria: Adequacy of budgetary allocation
by comparing country data to international benchmarks and other
countries Health sector allocative efficiency Criteria for
identifying childrens programmes Relative impact on children
compared to other population groups Programme that target women but
have implication on the health of children. By Albert Mwenda,
Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndenge, 10
Slide 11
RESULTS By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and
Godfrey K. Ndenge, 11
Slide 12
Kenya lags behind comparable developing countries like Rwanda
and Botswana that spend more on healthcare By Albert Mwenda, Robert
Peter Ndugwa, Isa Achoba and Godfrey K. Ndenge, 12 Source: UNDP,
2009. Human Development Report and WHO, 2011, Data and Statistics,
http://www.who.int/research/en/http://www.who.int/research/en/
Slide 13
Although the budget for the health sector increased in nominal
terms, as a share of total public expenditure it dropped from 7.4
percent in 2004/05 to 5.8 percent in 2008/09. By Albert Mwenda,
Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndenge, 13
Sectors2004/52005/62006/72007/82008/9 Productive
sector7.46.77.20.77.2 Public administration10.411.914.518.79.5
Physical Infrastructure13.514.617.720.625.9 Governance, Justice,
Law &order18.618.313.013.712.5 Health7.4 7.36.25.8
Education31.429.727.425.823.2 National Security9.79.88.29.68.2
ICT0.50.60.71.01.5 Manpower and special programmes1.00.93.93.76.2
Total sectoral expenditure (Ksh
Millions)257,951311,871378,976469,640598,364 Health expenditure as
% of GDP1.421.511.601.49 Source: MoMS, 2009; MoPHS, 2009
Slide 14
Adequacy of Public Health care Spending At the current level of
public spending on health care, financial targets have not been
achieved leading to a funding gap. As a result, the per capita
total expenditure on health was US $ 105 in 2006, falling short of
the average for the Sub-Saharan Africa at US $ 147.8. The current
public health care financing level is also way below the per capita
resource requirement for the Kenya Essential Package of Health
(KEPH) programmes estimated at US $ 35.2 in 2009/10 (Ministry of
Health MoH, 2005a) Health sector development expenditure has been
inconsistent and unpredictable, reflecting the unpredictability of
external financing and regular economic shocks. By Albert Mwenda,
Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndenge, 14
Slide 15
Examples of KEPH services and charges: These charges, though
nominal may be the difference between life and death but most
households can hardly afford. By Albert Mwenda, Robert Peter
Ndugwa, Isa Achoba and Godfrey K. Ndenge, 15
Slide 16
Adequacy of Public Health care Spending The Kenya government
has aligned its health allocation with a pro-poor focus by
increasing spending for Primary Health Services (especially in
health infrastructure development) BUT there has not been
commensurate increase in the budget allocation for permanent
employees and hence the ministries of health are not able to
attract and retain high calibre staff (there is 1 doctor for every
5,700 people in Kenya). Accelerated development of health
infrastructure is depleting common pool resources available for the
provision of other public services. Health ministries also face
difficulty in procuring and sustaining adequate and equitable
provision of essential healthcare supplies and equipments. By
Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K.
Ndenge, 16
Slide 17
Public expenditure on children and women-related programmes has
been less than 10 percent of the total public health sector
expenditure. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and
Godfrey K. Ndenge, 17 Source: RoK, various. Printed Estimates of
Recurrent Expenditures; RoK, various. Printed Estimates of
Development Expenditures. KEPI Kenya Expanded Programme on
Immunization.
Slide 18
Mismatch of children and women health care demands and
financing Nutrition: In 2007/08, less than 0.02 percent of health
sector budget of KSh. 25.6 billion was allocated to the Nutrition
Division within the MoPHS. In 2008/09, only 0.14 percent of the
total health sector budget was allocated to the Nutrition Division.
Reproductive Health Care: A significant proportion (38.4% in
2005/6) of the total reproductive health expenditure is borne by
households through the out-of-pocket OOP payments. In 2008/9, only
1.8 percent of the overall government expenditure on health was
spent on reproductive health services. Immunization: Budget
allocation for immunization programme did not exceed 1 percent
between 2003/4 and 2009/10. Sanitation: Management of sanitation
and hygiene programme needs better coordination across the several
ministries involved. By Albert Mwenda, Robert Peter Ndugwa, Isa
Achoba and Godfrey K. Ndenge, 18
Slide 19
Child and women programmes over-rely on donor funds which are
unpredictable By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and
Godfrey K. Ndenge, 19 Child and women related programmes (Figures
in KSh millions) 2005/062006/072007/082008/092009/10
GoKDonorGoKDonorGoKDonorGoKDonorGoKDonor Reproductive
health-54019428306694641,44117532 KEPI-5241132587-434202462-
Nutrition---137-----135 Total592606978936944981,643479667 Source:
RoK, various. Printed Estimates of development expenditure.
Slide 20
Over 90% of donor funds are managed outsides the mainstream
government budget and are disbursed in kind. This denies the
implementing agencies The flexibility to determine the quality of
goods and services delivered Reduces the ability of agencies to
respond to emergencies By Albert Mwenda, Robert Peter Ndugwa, Isa
Achoba and Godfrey K. Ndenge, 20
Slide 21
Adequacy of Health Care Finance The low per capita spending and
heavy donor reliance as well as inadequacies in the provision of
health care services reflects a huge financing gap in the health
sector. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and
Godfrey K. Ndenge, 21
Slide 22
User fees lower public health sector efficiency: Increase in
user fees in public sector facilities lowers utilisation of health
care services, diverts demand to private and mission facilities BUT
does not shift demand to traditional health care providers. By
Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K.
Ndenge, 22
Slide 23
Mechanisms through which user fees may lower efficiency in the
Public Health sector Leakage of revenue and therefore loss of
opportunity to improve public health care services (MOH, 2006).
District Health Management Boards (DHMBs) do not have full
authority to determine the use of the funds they collect. They are
required to submit budgets to the headquarters for approval. As a
result, DHMBs do not have the incentives to improve their
efficiency. Planning division of the ministry headquarters is not
appropriately staffed to effectively supervise and coordinate the
collection of user fees. In some cases user fees waivers and
exemptions are diverted to non- deserving patients, resulting in
loss of opportunity to improve health care delivery (MoH, 2006). By
Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K.
Ndenge, 23
Slide 24
User fees enhance inequality in health care access: The higher
the proportion of financial burden imposed on patients by cost
sharing, the lower the chances of them accessing treatment. By
Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K.
Ndenge, 24
Slide 25
User fees enhance inequality in health care access: User fees
are a regressive mode of financing health care since they impose
disproportionately higher costs of health care on the poor and the
chronically ill. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba
and Godfrey K. Ndenge, 25 Annual Per Capita Outpatient Visits to
Government Facilities and the OOP Spending on Outpatient Care as a
% of HH Expenditure, by Expenditure Quintiles, 2007. Source:
Authors computation based on RoK, 2009b. HH Health Expenditure and
Utilisation Survey Report 2007
Slide 26
DISCUSSION By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba
and Godfrey K. Ndenge, 26
Slide 27
Lessons Public health sector spending has been increasing but
is still below the recommended international standards and that of
many comparable countries. This limits access to health care among
children and women. It is evident that majority of the patients in
Kenya seek health care services in government facilities.
Naturally, therefore when funding for public health care is
disrupted: Household budgets are disrupted as many people seek
health care services in the more expensive substitute (private and
mission) facilities. Alternatively, health care may not be viewed
as a priority, leading to delayed treatment and ultimately
catastrophic health care costs Tax revenue and donor finance (as
demonstrated above) are susceptible to external shocks such as
financial crisis, foreign exchange fluctuations, political
conflicts and climate change. These shocks in turn affect the
sustainability of health care financing. By Albert Mwenda, Robert
Peter Ndugwa, Isa Achoba and Godfrey K. Ndenge, 27
Slide 28
Lessons BUT children and women programmes rely heavily on donor
financing which is unpredictable and inadequate to fully fill
resource gaps e.g. unfair staffing. Households bear a significant
proportion of the total health expenditure owing to high user fees.
User fees are a highly regressive mode of financing, requiring the
poor and the chronically ill to pay disproportionately higher
amounts for health care, than the rich. This limits access of
health care services by certain groups (especially children and
women). By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and
Godfrey K. Ndenge, 28
Slide 29
Some Proposals The government should progressively increase
budgetary allocations to children and women programmes and reduce
the programmes exposure to unpredictable donor funding. In order to
enhance allocative efficiency, there is need to institutionalise
district consultations through the Social Budgeting Framework. In
order to tap into private sector finance and enhance efficiency in
public health care, government should forge partnerships with the
private sector e.g. through lease agreements for provision of
health care supplies and equipments. In the long run, the
government should pursue policies that seek to eliminate user fees
for health care services, especially in facilities that are mostly
used by the poor. In this regard, the government should consider
expanding the social health insurance coverage. By Albert Mwenda,
Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndenge, 29
Slide 30
Some Proposals Deepen the Health Sector Services Fund (HSSF)
components that are meant to address equity issues in health for
children and women in deprived communities and vulnerable
populations. HSSF is an innovative direct transfer of funds to
dispensaries and health centres, started on 28th October 2010, with
Ksh. 143 million disbursed to 590 health centres across Kenya. By
Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K.
Ndenge, 30
Slide 31
Thank you By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and
Godfrey K. Ndenge, 31