1

IMPLEMENTATION OF THE CONSTITUTION IN

THE HEALTH SECTOR

This Position Paper presents the Health Sector’s position on key issues in relation to the implication of the

implementation of the constitution in the health sector. Its development was led by the Ministries of Medical

Services, and Public Health and Sanitation. Health Stakeholder consultations were carried out amongst the

existing Health Sector partners, to strengthen the inputs, and positions, and foster ownership.

POSITION PAPER

2

3

Contents 1 SECTION 1: INTRODUCTION AND BACKGROUND .................................................... 4

1.1 Background and rationale ............................................................................................. 4 1.2 Process of developing the position paper ...................................................................... 4 1.3 Outline of the position paper ........................................................................................ 5

2 SECTION 2: CURRENT SITUATION IN HEALTH .......................................................... 6 2.1 Overall health situation ................................................................................................ 6 2.2 Health Sector organization and investments ................................................................. 7

2.2.1 Leadership and Governance.................................................................................. 7 2.2.2 Health Care Financing .......................................................................................... 7 2.2.3 Health Workforce ................................................................................................. 7 2.2.4 Medical Products, Vaccines and Technologies ...................................................... 8 2.2.5 Health Information ............................................................................................... 8 2.2.6 Service Delivery systems...................................................................................... 8

3 SECTION 3: EMERGING ISSUES AND IMPLICATIONS ON THE HEALTH SECTOR9 3.1 The bill of rights and health........................................................................................ 10

3.1.1 The right to the highest attainable standard of health ........................................... 10 3.1.2 The right to emergency treatment ....................................................................... 10 3.1.3 Responsibilities of right holders and duty bearers ............................................... 10

3.2 The Health Sector and Devolution .............................................................................. 11 3.2.1 Criteria for transfer of functions to county governments: .................................... 11 3.2.2 Cross-county and multi government level health functions ................................. 12 3.2.3 County Health Facilities, Assets and Liabilities .................................................. 12 3.2.4 Managing shared responsibilities between National and County Governments .... 12 3.2.5 Procurement of Health Commodities at the County: ........................................... 13 3.2.6 Planning, budgeting and M&E at national and county levels for the health sector 13 3.2.7 Merger of ministries and other related services ................................................... 14 3.2.8 Health sector stakeholder partnership structures/frameworks .............................. 14

4 SECTION 4: SECTOR POSITIONS OPTIONS AND JUSTIFICATION .......................... 15 4.1 The Bill of Rights, and Health .................................................................................... 15

4.1.1 The right to the highest attainable standard of health ........................................... 15 4.1.2 The right to Emergency treatment ....................................................................... 17 4.1.3 Responsibilities of Rights Holders ...................................................................... 18

4.2 The Health Sector and Devolution .............................................................................. 19 4.2.1 Organization and Management of County Health Services .................................. 19 4.2.2 Criteria for transfer of functions to County Governments ................................... 24 4.2.3 Cross-county and multi government level health functions ................................. 26 4.2.4 County Health Facilities, Assets and Liabilities .................................................. 27 4.2.5 Managing shared responsibilities between National and County Governments .... 28 4.2.6 Management of Health Commodities at the County ............................................ 29 4.2.7 Planning, budgeting and M&E at national and county levels for the health sector 31 4.2.8 Merger of ministries and other related services ................................................... 32 4.2.9 Health sector stakeholder partnership structures/frameworks .............................. 32

5 SECTION 5: CONCLUSION AND WAY FORWARD .................................................... 35 6 REFERENCE INFORMATION ....................................................................................... 36

6.1 Key definitions ........................................................................................................ 36` 6.2 Primary Referral Hospitals distribution, by County .................................................... 39 6.3 References ................................................................................................................. 44

Page 4 of 44

1 SECTION 1: INTRODUCTION AND BACKGROUND

1.1 Background and rationale The promulgation of the constitution of Kenya by H.E. President Mwai Kibaki, CGH, MP, on 27th August, 2010 was a major milestone towards the improvement of health standards. Citizen’s high expectations are grounded on the fact that the new Constitution states that every citizen has right to life, right to the highest attainable standard of health including reproductive health and emergency treatment, right to be free from hunger and to have food of acceptable quality, right to clean, safe and adequate water and reasonable standards of sanitation and the right to a clean healthy environment. The Health Sector, therefore, needs to consolidate gains made in respect to provision of service delivery; leverage existing decentralized structures in health; and re-position itself to fulfil these expectations. The two ministries are under obligation to ensure that the right measures are put in place for successful implementation of Constitution.

Following the adoption by the Cabinet of the broad framework for the implementation of the Constitution, the respective Ministries embarked on a process to develop a framework for its implementation. This process was guided by the resolutions from the Retreat for Permanent Secretaries/Accounting Officers on the Implementation of the Constitution, held in Mombasa on 17th – 18th September 2010i.

As part of the implementation framework, various commissions and task forces have been established to guide the elaboration of the legal framework for implementation of the constitution. This position paper aims at guiding these respective constitution implementation committees, specifically the Commission for the Implementation of the Constitution and the Task Force on Devolution, on key issues relating to health, and what issues and positions need to be adapted, to enable the Country attain its long term Health Vision. It further outlines the Health Sector’s positions on key issues relating to the implementation of the constitution. These positions should help shape the work of the constitution implementing agencies.

1.2 Process of developing the position paper The development of this position paper followed comprehensive consultative processes, guided by the resolutions from the retreat of Permanent Secretaries’ and responses by the health ministries. As firstly, each one of the health Ministries (Ministry of Medical Services, and Ministry of Public Health & Sanitation) held a week long retreat facilitated by constitution experts, to better understand the constitution’s provisions and expected change required in focus and functioning.

Secondly, these Ministries responsible for Health summarized the constitution provisions that have impact on health mandate, identified and defined emerging issues, developed positions against these issues and elaborated an action plan, to guide implementation. Cross Ministerial task forces were established along the six Health System investment areas (Leadership & Governance, Service Delivery, Health Workforce, Medical Products, Health Financing and Health Information)ii, to bring together the emerging issues and positions into a coherent sector framework. This was

Page 5 of 44

reviewed together with constitutional consultants, to ensure comprehensiveness and coherence in the positions. Finally, the emerging draft position paper was presented to, and discussed with Development Partners (donors, and cooperating partners), and implementing partners (private for profit, and not for profit service providers, and Health NGO’s / CSO’s through the Health Network for NGO’s – HENNET) to elicit their views on proposed positions.

The emerging positions, therefore, have had the benefit of being aligned to the broad health sector directions, and have had stakeholder and expert input to ensure their relevance and coherence.

1.3 Outline of the position paper The paper is organized into 5 sections. The first three sections each focus on a different element required to understand the respective positions in section 4 on Health Sector positions with section 5 drawing broad implications relating to implementation of sector positions. In particular:

- Section 1 provides background information, and explains why the paper has been developed, and its development process.

- Section 2 presents a brief overview of the current health sector, and its challenges. - Section 3 presents a summary of constitution issues relating to health, and their

implications on the health sector. - Section 4 is the core of the position paper, and presents Health Sector positions on

various issues arising from constitutional provisions impacting on health. - Section 5 concludes the main body of the paper, and highlights some implications

relating to implementation / none implementation of the respective positions. - The paper ends with reference information and sources for further reading of different

issues highlighted in the position paper. It summarizes key health related definitions, reference material, and a summary of the interpretation of the different constitution provisions. Terminologies, for which definitions are provided, are underlined in the text.

Page 6 of 44

2 SECTION 2: CURRENT SITUATION IN HEALTH

In Kenya, the health imperatives that have been guiding actions in the health sector were elaborated in the Kenya Health Policy Framework, KHPF 1994 – 2010iii. Its strategic theme was ‘Investing in health’, with an overall stated goal as ‘To promote and Improve the health of all Kenyans through the deliberate restructuring of the health sector to make all health services more effective, accessible and affordable’. Six strategic imperatives were identified to enable it attain this goal. Medium Term focus to guide movement towards these policy imperatives was defined in Medium Term Strategic Plans, of which the current one is the 2nd National Health Sector Strategic Plan of the KHPF (NHSSP II, 2005 – 2012).

2.1 Overall health situation A review of the health situationiv shows that the health status of the people in Kenya has only marginally improved in the past, with reductions in Life expectancy (LE) (54.7 years in 1999, to 53 years in 2006) noted. Age specific health impact indicators show stagnation / worsening of the health situation, which was just beginning to improve at the end of the policy period for specific age cohorts (see diagram below).

Trends in Health Impact indicators during the period of the policy review

Source: Respective Demographic and Health Surveys

Geographical and sex differences in age – specific impacts persist. Additionally, death, and ill health is being contributed to by many different conditionsv. HIV/AIDS is responsible for up to 29.3% of all deaths, and 24.2% of all disability in the country. Other causes of death include conditions during and just after birth (9% of deaths), respiratory (chest) infections including Tuberculosis (14.4% of deaths)), diarrhoeal diseases (6% of deaths), malaria (5.8% of deaths), stroke (3.3% of deaths), heart attacks (2.8% of deaths), road traffic accidents (1.9% of deaths), and violence (1.6% of deaths).

Page 7 of 44

Many interventions have been introduced, particularly since 2004, to address the high burden due to communicable diseases. As a result, increased investments in HIV, Malaria, Tuberculosis control, Maternal and Child Health have been made. Additionally, investments in risk factors to health, such as tobacco and alcohol use are being prioritized. These investments are complemented by investments in other health related sectors, such as in Nutrition, access to safe water, education, roads and others, to contribute to the overall improvement in health.

2.2 Health Sector organization and investments This is understood and described around six building blocks of Health Services Delivery

2.2.1 Leadership and Governance Two Ministries provide leadership in Health – the Ministry of Medical Services (MOMS) and the Ministry of Public Health and Sanitation (MOPHS). Their functions are defined according to the mandates as defined by Governmentvi.Coordination of service delivery is done through a Sector wide approach, the Kenya Health SWAp (KHSWAp)vii that brings together all Health Stakeholders and is managed through a partnership instrument: the Code of Conductviii. The Code works through coordination mechanisms at all the management levels of the system that bring together all recognized health stakeholders to discuss and agree on sector focus. The national level has the Joint Interagency Coordinating Committee (JICC), Health Sector Coordinating Committee (HSCC), and Interagency Coordinating Committee’s (ICC’s). Provincial and District levels have respective stakeholders’ fora. Governance structures and systems also exist, through boards at the respective service delivery levels (hospitals, and districts). A common framework for planning and implementation is in place, with decentralized sector wide annual work plans, and monitoring processes in place and applied. However, capacity gaps still exist in leadership and governance. Harmonization of health laws around an updated Health Act is not completed. Leadership and Management skills mix is still patchy, particularly at the sub national levels. Incomplete adoption of partnership processes at some levels of the sector implies some key partners are not appropriately engaged when required. Additionally, key health related sectors are not fully engaged by the Health Ministries, to allow for comprehensive addressing of the health agenda in the country.

2.2.2 Health Care Financing Financing of Health Care is sourced from the public, private including households (consumers), and donors. Current estimates of Health Spending show Households remain the largest contributors of health financing, at 35.9 percent, followed by the government, and donors, who contribute approximately 30%ix. The high out of pocket household expenditures and the dependency on donors, especially for priority interventions, raises issues of sustaining the investment in the health sector and improved health outcomes. Key priorities being pursued to rectify this include continued push for increase in Government Health Expenditures, reduction in out of pocket spending through the 20/10 policy, strategies to eliminate fees at point of use, and exploration of pre-payment mechanisms such as establishment of a National Social Health Insurance Scheme as a future focus of equitable health financing.

2.2.3 Health Workforce While the country has a relatively high number of health workers as compared to other countries in the sub Saharan Africa region (1.69 Health Workers, per 1,000 populations), there are still acute shortages of critical health workers for some staff cadres. Additionally, there is unequal distribution of workers, by urban/rural areas, by regions, and by level of care. More

Page 8 of 44

health workers exist at higher levels of service delivery, due to better incentives (financial, and others). Retention and brain drain problems are limited to some areas of the country particularly some cadres – with overall turnover rates for health workers still very low at 3 – 4 % (Nursing turnover is 13% in the USx). The Economic Stimulus Package, and targeted donor support have supported absorption of many health workers, particularly nurses, across the country to reduce distribution inequalities. Weak Health Workforce Management practices have led to various training programs, particularly for in service staff. Improved coordination and management of these training programs is a sector priority at present.

2.2.4 Medical Products, Vaccines and Technologies There are ongoing endeavours to strengthen management of Medical Products and technologies, with emphasis being placed on ensuring Medical Products and Technologies are accessible and affordable, meet the defined standards for quality efficacy and safety, and are appropriately utilizedxi. Kenya National Pharmaceutical Policy and Sessional Paper have been developed targeting revision of the regulatory framework and establishment of the Kenya Medical Supplies Agency as an autonomous organ to competitively procure, warehouse, and distribute medical products for the sector. The regulation of Medical Products and Technologies continues to be a challenge, due to various competing interests in the field, and institutional weaknesses in the sector. Additionally, financing for Medical Products and Technologies still remains very low, in spite of the critical role they play in overall health service delivery.

2.2.5 Health Information Efforts have been made, in defining a comprehensive Health Information System that places emphasis not just on information generation, but also analysis and usexii., Information from other health related sources, such as from census and vital statistics; surveys; surveillance; other population- and facility-based statistics and research; management statistics; are increasingly being used. ICT solutions are being applied, such as the File Transfer Protocol System for better information availability on selected indicators, and the newly introduced District Health Information System for more comprehensive information generation and analysis at sub national levels. Information analysis and communication is also being further strengthened through implementation of a Country Knowledge Management Frameworkxiii. On the other hand, poor resourcing of Health Information function and development, and use of parallel information generation systems particularly from programs / projects duplicates efforts, further constraining the already weak information capacity.

2.2.6 Service Delivery systems Health Service Delivery is organized around 6 levels of care, from the community (level 1), to the national level (level 6)xiv. Each level has both service delivery, and Management functions. The services delivered at each level are defined according to the norms and standards. Similarly the management function is physically distinct from the service delivery function at level 4 (district – Office of the District Medical Officer), level 5 (province – Office of the Provincial Medical Officer), and level 6 (national – MOH Headquarters). The management level has expanded over time, and there increasing capacity for development of policies, guidelines and regulations, conduct of evaluations, analyses and studies. Service delivery function is rationalized, based on the need to efficiently, but effectively deliver the defined set of services in the Kenya Essential Package for Health (KEPH). A referral system is being strengthened, to improve linkages across the service levels and so ensure a more wholesome health care seeking effort by the population.

Page 9 of 44

3 SECTION 3: EMERGING ISSUES AND IMPLICATIONS OF THE CONSTITUTION ON THE HEALTH SECTOR

All the provisions of the constitution will affect the health of the people in Kenya in one way or another. However, two critical chapters introduce new ways of addressing health problems, and have direct implications to the health sector focus, priorities and functioning. These are the chapters on the Bill of Rights, and the devolved Government. The table below summarizes the key relevant Articles from these Chapters.

Main constitution articles impacting on the health sector

ARTICLE CONTENT 20 20a) Responsibility of State to show resources are not available

20 b) In allocating resources State will give priority to ensuring widest possible enjoyment of the right

43 (1) a) and b) Right to highest attainable standard of health, reproductive health, sanitation

(1) c) the freedom from hunger and adequate food of acceptable quality(2) A person will not be denied emergency treatment

26 Right to life - Life begins at conception - No person deprived of life intentionally - Abortion is not permitted unless for emergency treatment by trained professional

32 Freedom of conscience, religion, belief and opinion 53-57 Rights of special groups:

-Children have right to basic nutrition and health care. -People with disability have right to reasonable access to health facilities, access to materials and devises -Youth have right to relevant education and protection to harmful cultural practices and exploitation Minority and marginalized groups have right to reasonable health services

174 Objectives of devolution Vs fourth schedule on roles; National: Health policy; National referral facilities; Capacity building and technical assistance to counties County health services: County health facilities and pharmacies; Ambulance services; Promotion of primary health care; Licensing and control selling of food in public places; Veterinary services; Cemeteries, funeral parlours and crematorium; Refusal removal, refuse dumps and solid waste Staffing of county governments: Within frame work of uniform norms and standards prescribed by Act of Parliament establish and abolish offices, appointment, confirmation and disciplining staff except for teachers

176 County Governments will decentralise its functions and its provision of services to the extent that it is efficient and practicable

183 Functions of County Executive Committee’s 235 Transfer of functions and powers between levels of Government

This section reviews these provisions under the Bill of rights, and Devolved Government – with an aim of highlighting emerging issues for which action is needed. Sector positions in the following section are meant to address these emerging issues.

Page 10 of 44

3.1 The Bill of rights and health The Bill of rights provides guidance to the sector, on the definition and policy understanding of the content of the right to the highest attainable standard of health. It uses nomenclature of International Human rights instruments. Its contents can be summarized into:

- The right to the highest attainable standard of health, including the right to life, reproductive health, and other attributes of good health

- The right to emergency treatment, and

- Clarity on responsibilities of the State (duty bearers), and citizens (right holders)

3.1.1 The right to the highest attainable standard of health There are requirements for national reporting every year on progress made in regard to the realization of rights. This means that there is need for identification of a baseline to anchor the concept of progressive realization.

The concept of progressive realization also requires on one part clear macro level policy positions consistent with the minimum core content of the right to the highest attainable standard of health supported by the necessary resources to achieve the same.

Flowing from the right to the highest attainable standard of health is the issue of determining the minimum core content and package of services that the State guarantees every person.

Appurtenant to the issue of the right to the highest attainable standard of health is the issue of reproductive health and rights. It will be critical for the sector to have clear positions on this, in the context of the right to the highest attainable standard of health.

Based on these understanding, the sector will need to determine the core content of the right to the highest attainable standard of health through positions relating to:

i. Package of Health Services: ii. Content of reproductive health care rights

3.1.2 The right to emergency treatment The Constitution provides that persons cannot be denied care, in an emergency situation. As a result, it is crucial that there are clear positions to guide how this will be made operational, particularly in relation to private health care providers, where cost recovery is a major part of the services being provided. Additionally, roles and expectations of service providers need to be clear. Clear positions, therefore, are needed on:

i. Conditions that give rise to emergency treatment

ii. Scope of emergency treatment

iii. Professional indemnity in cases of providing emergency treatment

3.1.3 Responsibilities of right holders and duty bearers The right to the highest attainable standard of health as seen from the constitutional provisions has a number of determinants including the behavior of individuals and corporate bodies. The Constitution enjoins all persons to promote and protect it and hence every person is seen to have a role in the realization of its objectives. With respect to the health sector there is

Page 11 of 44

therefore need for policy clarity on what such role entails. There is a correlated issue of the different roles of stakeholders in the health sector in regard to public education on health related issues.

It is crucial therefore that clear positions be available that speak to among other things:

i. Responsibilities of duty bearers to emergencies services ii. Responsibilities that arise for the individual with respect to realizing the right to health iii. The inter play between access to information in regard to the right to privacy

3.2 The Health Sector and Devolution A key area that has a number of emerging issues of critical concern and policy focus is that of devolved level of government. Firstly this is seen against the principles underpinning devolution. The Constitution legislates on a number of issues relating to devolution, and a review of these shows there are issues for which the health sector will need to have clear direction on, relating to:

- Organization, and management of county health services

- Criteria for transfer of health related functions to County Governments.

- Cross County, and multi Government level functions in health.

- County health facilities, assets and liabilities.

- Management of shared responsibilities between National, and County Governments.

- Procurement of health commodities at the County.

- Planning, budgeting and M&E at national and county levels for the health sector.

- Merger of Ministries, and other health related services.

- Health Sector stakeholder partnership arrangements.

3.2.1 Organization, and management of County Health Services The elaboration of the devolution system in the constitution has defined a new level of service delivery, different from the existing levels (province and district). The Sector needs to define how this level will be organized, and the delivery of health services managed from the County down to the Community. Specifically, positions will be defined in relation to:

i. Description of the county health system ii. Management of health at the County iii. The role of the County Health Management Team iv. Management of Health functions at the sub county level

3.2.2 Criteria for transfer of functions to county governments: The Constitution is clear that the transfer of functions from national government to county governments is expected to run over a period not exceeding three years as specified in the transitional provisions. The same provisions require national legislation to provide criteria that must be met before these functions are transferred.

Looking at the status of health care provision capacity in the country and the high levels of inequality that exist in the country, it is clear that the transfer of functions to Counties will take

Page 12 of 44

place at different times. There is need to address this inequality issue through robust capacity building programs and affirmative action. Against these issues positions are therefore required to address:

i. Sequencing transfer of functions ii. Capacity building programs targeting delivery of health services within the county iii. Available human resources and health professionals required to carry out the necessary

function iv. County level policy frameworks to implement the national level policy v. Operational plans, and County level health sector budgets

vi. Affirmative action programs and target Counties

3.2.3 Cross-county and multi government level health functions There are health sector concerns that go beyond the boundaries of a single County or require cross County intervention. These could include pandemics and other public health issues. Additionally, there are some public health programs that require national implementation using standard regimes and administration. These would as of necessity require national government intervention and action. There is therefore need for clear positions on:

i. Type and classification of cross-County health issues ii. Management and implementation of cross-County Public health program issues iii. Multi-government response to health issue

3.2.4 County Health Facilities, Assets and Liabilities As provided for in the Constitution the County government is mandated as guided by national standards to hire its Public Service personnel at the County level. National Government will only hire health professionals for the national level. The bulk of the health personnel will indeed be at the County level. Furthermore, at the point that County’s take over the functions envisaged in the fourth schedule of the Constitution they will inherit assets that have hitherto been managed and run by national government or local authorities. This calls for the development of an in depth inventory of assets. There are assets that have served More Than One County and as such there is likely to be disputes as to the ‘home’ of these assets. Assets under the provincial administration system will most likely give rise to questions as to the true nature of these facilities whether they are national or county level assets. A problematic issue relates to the liabilities that will come with transfer in ownership of assets to county governments. There will likely be issues as to who should properly liquidate any such liabilities and what the respective roles of the two levels of government should be. It is in this light that there is need for policy positions that speak to:

i. The standards required for hiring of health professionals at the County ii. Minimum working conditions and terms of service iii. Inventory of all assets within health sector and their current location within counties iv. Liquidation of liabilities

3.2.5 Managing shared responsibilities between National and County Governments As stipulated in the Constitution both levels of government are distinct though required working in collaboration, consultation and cooperation. The management of the health sector through a centralized system does indeed reduce the chances for duplicity of functions. Under the

Page 13 of 44

devolved system of government both levels of government have aspects of service delivery and policy making and thus duplicity is highly likely. A sector position on how to manage such duplicities is needed.

i. Responsibilities of National, and County Governments in Human Resource Management:

ii. Regulation of the Health Workforce

3.2.6 Procurement of Health Commodities at the County: As noted earlier there has been some progress with respect to procurement and management of pharmaceutical commodities. This paper here before noted the following challenges such as weaknesses in the institutional framework to carry out medical products management, shortage of staff to support various functions, an increasing need to strengthen pre-service training at the tertiary level, to align skills with the requirements of the health sector, low budgetary allocation to support the Medium Term procurement plan as significant contributors to drug shortages at public health facilities.

These and other challenges will be exacerbated by the two levels of procurement now made possible by the two levels of government. The shortage of human resources will only become more apparent as various Counties seek to carry out their mandates. While the law is clear on public procurement procedures, lack of standardized procedures, distribution systems, mechanisms for promoting appropriate use of medicines and systems for managing and qualifying suppliers need be addressed.

The role of State corporations and in particular KEMSA will need some attention. Whereas KEMSA carries out its role as required by the law, the distinct nature of the two governments may result in County’s wanting to employ independent procurement frameworks or in some instances working with and through KEMSA as individual governments.

There is need therefore for positions to speak to:

i. Levels of maintenance of supplies of essential drugs in the various health facilities

ii. Management of procurement of Medicines and Medical Supplies iii. The role of KEMSA iv. Procurement process by County Governments v. Minimum inventory standards for Medical Products and Supplies

3.2.7 Planning, budgeting and M&E at national and county levels for the health sector

Seen through the lenses of constitutional provisions, both levels of government have aspects of service delivery, planning, budgeting and policy making. These functions are however expected to comply with national values and principles, the Bill of Rights and national policy and legislation for the Health Sector. This policy and legal framework must however itself recognize that the two levels of government are distinct and therefore leave scope for policy development and innovation for implementation at the County level. Kenya has historically had challenges with respect to coherent planning between the national and the sub- national levels. In the new dispensation that has two levels of government the need for joint approaches and platforms for planning and budgeting is paramount.

Secondly as guided by the Bill of Rights and provisions targeting special groups such as women, youth, children, persons with disabilities, minorities and marginalized groups, the template for

Page 14 of 44

planning and budgeting must be alive to the particular health related rights and issues of these groups. This calls for not only mainstreaming of these groups in planning cycles but much more in-depth disaggregated planning. This of necessity calls for development of national standards against which both levels of government will be expected to report against annually as required by the Constitution.

In regard to national reporting, the framework employed currently is not rights focused and as such needs the development of necessary indicators to allow for collection of necessary data for national reporting within frameworks such as NIMES.

With this in mind clear policy positions need to be crafted that speak to:

i. Health Strategic direction ii. Coordination mechanisms joint planning, budgeting and reporting iii. Development of national and county level disaggregated indicators for reporting iv. Efficiency and effectiveness of technical assistance/capacity building to county

government

3.2.8 Merger of ministries and other related services The Constitution creates limits to the size of the cabinet both at the national and county levels. The immediate implication of this is that there are fairly high chances for merger of the two ministries (Public Health and Sanitation and Medical Services). This is not problematic at the national level but will present some challenges at the County level. It is envisaged that the Executive Committee in the County will be no larger than 10 in memberships. This will practically result in some of the ministries at the national level working with a peer County function carried out by a merged department. For instance it is likely that the department of health in the County may come under a merged department of social services. There is therefore need for the national level health ministry to develop a policy position and proposal on the best way to deal with this issue. In particular policy proposals should address:

i. Status of a Health Ministry ii. Structure and functioning of the Health Ministry

3.2.9 Health sector stakeholder partnership structures/frameworks The health sector is by its very nature a multi stakeholder and role player sector that sees actors ranging from government, private sector, faith institutions, and development partners involved in service delivery. This in a centralized system has already posed many challenges which will significantly be heightened under a devolved structure of government. The Constitution is clear that the primary obligation falls on the State on all fronts ranging from policy development to service delivery. In this light it is crucial that the health sector coordinating mechanisms have policy positions that speak to:

i. The proposed roles for all stakeholders in the health sector ii. The nature and scope of joint planning, budgeting at the national level iii. Monitoring, evaluation and reporting by Non State actors in the health sector iv. Managing Public Private Partnerships in the health sector v. Managing stakeholder partnerships in the health sector:

Page 15 of 44

3.2.10 The Financing of Health Care The Constitution provides for the right to highest attainable standard of health as well as the right to emergency treatment. In addition, the Government will be expected to demonstrate that they are progressively working towards meeting the healthcare needs of the minority and marginalised groups. This implies that Government will have to take lead in the development of mechanisms of ensuring that nobody is denied care in both public and non-public health facilities and that the costs of providing such services are defrayed, especially in cases where some people are unable to meet them, In this regard, it is imperative that the health sector develops positions that address:

i. The mechanism that will be used to ensure that indigents are not denied care in both public and non-public health facilities;

ii. The way costs related to emergency treatment will be met in both public and non-public health facilities; and

iii. The mobilization of financial resources to ensure that all regions and groups achieve equitable health care services.

4 SECTION 4: SECTOR POSITIONS OPTIONS AND JUSTIFICATION

The Health Sector positions herein have been elaborated in response to the emerging issues noted in the previous section. As with the previous section, the positions relate to provisions that introduced major transformation affecting health services under the chapters of the Bill of Rights and that of Devolved Government. For each emerging issue, a position is elaborated.

4.1 The Bill of Rights, and Health

4.1.1 The right to the highest attainable standard of health POSITION 1: Package of Health Services: There will be a defined package of primary health

care services to which every person will be entitled to. It will comprise services addressing diagnosis treatment of common conditions, disease prevention activities and health promotion, and referral of serious illnesses. Physical and Financial access to this package of services to the right holder will be ensured by the duty bearer, in a manner that incorporates principles of universal access, efficiency, effectiveness and social protection. JUSTIFICATION: A defined package of services allows both the duty bearers (the State), and the right holders (the citizens) know exactly what services to expect with the available resources.

POSITION 2: Content of reproductive health care rights: Duty bearers will provide services to

ensure men and women right holders have access to quality sexual and reproductive health while taking cognisance of the defined primary health care package. This includes:

Page 16 of 44

- the right of men and women to be informed about, and to have access to family planning services, except those against the law. the right of access to appropriate health-care services that will enable women to go safely through pregnancy, childbirth, and the post delivery period

- the right of access to appropriate health-care services that address reproductive health related conditions across gender and age groups

- Access to appropriate treatment by a trained health professional for conditions occurring during pregnancy where the life or health of the mother is threatened. These include abnormal pregnancy conditions, such as ectopic, abdominal and molar pregnancy, or a medical condition exacerbated by the pregnancy to an extent that the life of the mother is at risk.

JUSTIFICATION: Reproductive Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive health system and its functions and processes1. To achieve this, the right holders need to have access to, and use of services that enable them have a full and satisfying sex life. The constitution legislates on the right to life, recognizing that it begins at conception, no person will be intentionally deprived of life, and that abortions are illegal, and is only permitted where the life or health of the mother is in danger and will be carried out by a trained health professional.

POSITION 3: Basic nutrition rights: Duty bearers will provide services to ensure that all

Kenyans are aware of their nutritional needs throughout their lifecycle and have access to acceptable, quality, safe and adequate foods for optimal nutrition and nutritional services while taking cognisance of the defined primary health care package, including: - Ensuring optimal growth and survival of children through regulation and

protection of children’s right to basic nutrition; and - Mitigating the negative health, social and economic impact resulting from

the excessive exposure to inappropriate foods and refined foods.

JUSTIFICATION: Nutrition covers all the areas of food consumption that have positive or negative effect of human health and the human nutrition. It includes all aspect of food intake which covers nutrient content of food for both nourishment and pharmacological treatment; availability and access; social cultural and psychological aspects; food safety; nutrition surveillance; nutrition education; nutrition care and support in disease management; food and

1 World Health Organization definition of Reproductive Health

Page 17 of 44

nutrition social security and nutrition epidemiology of safety, quality and quantity.

POSITION 4: Environmental health and sanitation: The health sector will ensure that

institutions/ authorities that have been charged with the responsibilities to protect and sustain health environment carry out their mandates to the latter. This will be achieved by strengthening the public health laws that deal with the Environment, safe water and food.

JUSTIFICATION: The regulatory mechanisms on the protection of thehuman environment will be provided in health related Acts.

4.1.2 The right to Emergency treatment

POSITION 5: Conditions that give rise to emergency treatment: Emergency treatment will be considered in medical conditions that consists all the following:

- Are of sudden onset in nature;

- Are beyond the capacity of the individual / community to manage; and

- Are life threatening, or will lead to irreversible damage to the health of the individual / community if not addressed.

The emergency treatment will be provided by the health facility of first contact regardless of ownership.

JUSTIFICATION: The Health Sector recognizes health care emergency services as those services necessary to prevent and manage the damaging health effects from an emergency situation. The scope of emergency services should include and not limited to:

a. Pre-facility care of patients and those with injuries;

b. public health information on emergency treatment, prevention, and control; and

c. Administrative support including maintenance of vital records and providing for a conduit of emergency health funds across Government.

Emergency care involves arrangements for transfer to clients once the emergency nature of the service is stabilized. Execution of these transfer arrangements ends the emergency phase of health care. Provision should be made with regard to the actual and related cost of emergency health care.

POSITION 6: Scope and financing of emergency treatment: The emergency health services shall include but not limited to (1) stabilizing the health status of an individual with a life threatening condition (2) where needed, arranging for transfer of clients once the emergency nature of the service is stabilized.

Page 18 of 44

Financing of emergency treatment: in order to defray the cost of providing emergency treatment, an appropriate mechanism will be established for financing costs incurred by facilities for emergency treatment.

JUSTIFICATION: In an emergency situation, the focus will be to save life and limit the negative effects arising from the emergency. As health facilities are of different capacities, referral of the individuals where additional capacity is needed is part of the emergency phase.

4.1.3 Responsibilities of Rights Holders and Duty Bearers POSITION 7: Responsibilities of duty bearers to disaster and emergency services: The duty

bearers shall have the capacity and responsibility to manage all emergencies and disasters. Where their capacity to respond is exceeded by the emergency, a state of emergency should be declared, to draw on external resources to facilitate the response. The State will mobilize all resources available (public and Private) to combat large scale emergencies and disasters.

JUSTIFICATION: Whereas the state has an obligation to to ensure that the right holders are not denied emergency treatment and responds adequately incase of disasters, the right holders are obliged to not expose themselves to unnecessary danger to their lives.

POSITION 8: Responsibilities that arise for the individual with respect to realizing the right to health: Attainment of the right to health is a responsibility that should be shared between the duty bearers -State and its organs (including its partners) – and the right holders – the people. The individual right holders will be expected to:

- Exercise the appropriate behaviour required to maintain their health;

- Seek health care intervention at the earliest possible moment; and

- Take up health care services made available, to maintain their health, particularly disease prevention and control services.

The duty bearers will be expected to:

- Making available required information to ensure the right holders are realizing their right to health

- Ensure right holders are informed of the services available, and their expectations in accessing and using these services

JUSTIFICATION: the benefits of the Bill of rights are shared between the duty bearers (a healthy, and productive nation), and right holders (adequate health to allow for a better quality of life). They therefore both have obligations, in guaranteeing this right. It cannot be attained, if they each do not perform their expected roles.

Page 19 of 44

POSITION 9: The relationship between access to information in regard to the right to confidentiality: The confidentiality of patient information will be of paramount importance, and should only be over-ridden in special circumstances (public health protection and health research) which should be captured in law as provided for in the Constitution.

JUSTIFICATION: Provision of Health Services involves sharing of personal information by right holders, with the duty bearers. This information is very critical for appropriate health care service provision, and is only shared on the understanding that the duty bearers will hold such information in confidence. The right holders need to continue to know their information is held in confidence, and can only be shared under a clear, legal mechanism and in special circumstances.

4.2 The Health Sector and Devolution

4.2.1 Organization and Management of County Health Services POSITION 10: National health services: The Ministry responsible for Health at the national

level will be responsible for policy development; referral system; standards and regulation; training and research.

These services will be provided through the national office; semi-autonomous institutions responsible for the provision of specialised services and tertiary referral facilities which provide highly specialized services, including (1) General specialization , (2) Discipline specialization and (3) Geographical / Regional Specialization and equivalent non state health facilities.

JUSTIFICATION: The Constitution envisages a situation where county services are properly directed and regulated to ensure that the established norms and standards in health are not compromised. In addition some of the services are of specialised nature while others such as training and research have costs and benefits that may go beyond the requirements of the county system.

POSITION 11: Description of the county health system: County Health Services will be organized around 3 levels of care: Community, Primary care, and Referral services. Community level will focus on organizing appropriate demand for services, while (Primary Care and primary clinical services) will focus on responding to this demand. The National and County Governments should to ensure that all health facilities have the capacity to provide primary care, including emergency services.

Page 20 of 44

- The Community services will comprise of all community based demand creation activities, organized around the Comprehensive Community Strategy defined by the Health Sector.

- The Primary care services will be comprised of all dispensaries, health centers, Clinics, nursing homes and other non state providers. Their capacity will be upgraded, to ensure they can all provide appropriate services

- The Primary health services will include all level 4 hospitals, which will be referred to as County Hospitals. They will each be expected to have at least 50 inpatient beds and provide specialized services that include operations, mortuary, radiology units with x-ray and resident medical practitioners or dentists.

- JUSTIFICATION: Health services at the county and below are to be re-organized to facilitate attainment of objectives of devolution - powers of self governance and enhancing participation in decision making, protection of rights of minorities and marginalized communities, improving access and equity in service provision, and decentralization of state functions closer to beneficiaries. The County health system will, therefore, comprise all the current designated health facilities and

management systems from the community to the district level. At present, each County has more than one primary hospital (see Annex 3: Hospitals by County), which by definition should contain the expertise and capacity to provide a range of specialized services. However, counties will be free, within their resources to upgrade the facilities to such levels of specialization as may be technically and economically feasible. Efforts will also be made to the health facilities in the county work together as ONE unit, to ensure comprehensive provision of specialized health services. This is in line with World Health Organization recommendations that focus on integrated service delivery models that emphasize efficiency, access, and equity in resource use, and take into account the role a strengthened referral system plays, vis-à-vis construction of large facilities which, while politically good, are an inefficient use of available health resourcesxv, xvi, xvii. This implies the strengthening of the referral function across these hospitals by the health sector through the application of standards and norms.

Page 21 of 44

Re-organization of health services delivery

NATIONAL HEALTH SERVICES Comprise all secondary and tertiary referral facilities, which provide highly specialized services. These include (1) General specialization , (2) Discipline specialization and (3) Geographical / Regional Specialization (7 Provincial facilities) and equivalent no state health facilities. These should focus on provision of:

Highly specialized health care, for area / region of specialization Training and research services for issues of national importance

COUNTY HEALTH SERVICES Comprise all level 4 (primary) health facilities in the county and as defined in the constitution including those managed by non-state actors.

Comprehensive in patient medical and surgical care, including reproductive health services

Facilitate, and manage referral/ambulance services from level 2’s, and to level 4’s Control and licensing of food outlets; veterinary services; cemeteries; funeral parlous and crematoria

PRIMARY CARE SERVICES Comprise all level 2 (dispensary) and 3 (Health Centres) facilities in the county including non state actors, including services defined in the Constitution:

Disease prevention services, such as immunization Basic outpatient medical and surgical services, Limited inpatient services for emergency clients awaiting referral, clients

for day observation, and normal delivery services Facilitate referral of clients from Communities, and to Level 3 facilities Refuse removal, refuse dumps and solid waste disposal

COMMUNITY HEALTH SERVICES Comprise community units in the county. Should focus on

Ensuring individuals, households and communities carry out appropriate healthy behaviours, and recognize signs and symptoms of conditions that need to be managed at other levels of the system, and

Facilitate community based referral. CO

UN

TY

HE

AL

TH

MA

NA

GE

MEN

T T

EA

M

MOH HQ’S

COUNTY HEALTH

MANAGEMENT TEAM

HEALTH FACILITY

MANAGEMENT TEAM

COMMUNITY HEALTH

COMMITTEE

Ministry Headquarters and

Semi-Autonomous Institutions

Referral services

Referral services

Referral services

Page 22 of 44

POSITION 12: Management of health at the County:

A new health management structure will be established at the County, to coordinate and manage County health Services. The structure will be as follows:

County Director of health Services

Health Promotion and Disease Prevention

Environmental Health and Sanitation

Veterinary services

Clinical and rehabilitative services

Pharmaceutical services

Planning , monitoring and health information

Administration and Finance

JUSTIFICATION: A management team will be required to coordinate the following County – level Health Management functions:

- Provide leadership and stewardship for overall health management in the County,

- Provide Strategic and operational planning, Monitoring and Evaluation of health service delivery in the county.

- Provide a linkage with the national Ministry responsible for health. - Collaborate with State and Non state Stakeholders at the County and between

counties in health services - Mobilize resources for County health services - Establish Mechanisms for the referral function within and between the counties,

and between the different levels of the health system in line with the sector referral strategy

POSITION 13: The role of the County Executive Department responsible for health:-

- The County Director of health services shall be a member of the County Executive Committee (CEC). The role of the County Executive Department responsible for health is as stipulated in the fourth Schedule of the Constitution of Kenya 2010.

- - County Director of health Services: - The County Director of Health will be responsible to the County Governor for

organization, control and coordination of health services at the county level. She/he will be responsible for providing leadership, management and coordination of all health services at the county level.

- - County health management structure shall consists of the following:- -

(a) Primary health Care: Provision of leadership, management and coordination of Primary health

Page 23 of 44

care and disease prevention in particular - maternal and child health, - nutrition, - non communicable and communicable diseases, - common disease, - HIV and aids, - oral health, - occupational health, - mental health and substance abuse, - infection prevention and control - eye health, - disease surveillance l.

(b) Environmental Health and Sanitation:

Provision of leadership, management and coordination of - licensing and control of Undertakings that sell food to the public; - cemeteries, funeral parlours and crematoria; - refuse removal, refuse dumps and solid waste disposal, - veterinary , - pollution control, water safety,

(c) Veterinary services

Provision of leadership, management and coordination of veterinary services excluding regulation of the profession

(d) Clinical and rehabilitative services Provide leadership, management and coordination of health facilities function in particular clinical care including alternative medicine, emergency medical services including referral, diagnostic services, blood transfusion and tissue transplantation, rehabilitation services, reproductive health emergencies

(e) Pharmaceutical services Organization, planning, leadership, control, monitoring and evaluation of pharmaceutical services - management of pharmaceutical services - Oversee implementation of the KNPP - Provide advice on pharmaceutical trade and pharmacy practice - Coordinate capacity building for pharmaceutical human resource - Coordinate the activities of the institutional medicines and therapeutics

committees - Establish and maintain a medicines information resource centre

Page 24 of 44

- Establish and maintain a mechanism to continuously review and address medicines safety and quality

- Recommend and facilitate licensing of pharmaceutical distribution channels as per national standards

(f) Planning and monitoring:

- Coordination of strategic and operational planning and monitoring, including information generation, validation, analysis, dissemination and use. Health information relates to health surveys, birth / death registration, census information, health facility data, and management information

(g) Administration and Finance

Provide leadership and stewardship in support functions in particular: - Human Resource Management and Development Policies - ICT - Supplies chain management - Finance management and logistics - Internal Audit - E-health - Public private partnership

JUSTIFICATION: Establishment of a County Executive Department responsible for Health, will ensure effective and efficient management of health Services at the county.

POSITION 14: Management of Health functions at the sub county level: The sub county

health management function should be restructured to focus on coordination for Public Health functions amongst the primary care facilities, and community units. JUSTIFICATION: A sub county structure will be required, to support coordination of primary care and community services for the sub-county units within the County.

Criteria for transfer of functions to County Governments POSITION 15: Sequencing transfer of functions: The National Government in transferring

Health functions to County government should: Carry out a comprehensive inventory of infrastructure, personnel,

equipment, supplies and commodities in the 47 counties. Carry out functional review to determine staff establishment, facility,

equipment, infrastructure needs at all County levels. Ensure and support Counties to set up the proposed County Health

Management teams. Transfer of assets to the County based on performance assessment guided

by agreed mechanisms

Page 25 of 44

JUSTIFICATION: The Ministry over the years has been strengthening its district management systems. The sector is better prepared to transfer health services to County governments. What is required is to establish an operational County management health team to provide leadership.

POSITION 16: Capacity building programs targeting delivery of health services within the county: The Ministry should establish regional units/satellite offices including use of existing decentralised structures to build capacity of counties in collaboration with other stakeholders. JUSTIFICATION: There is need to efficiently offer continuous capacity building and technical support, to enhance performance of counties.

POSITION 17: Available human resources and health professionals required to carry out the

necessary function: The optimal Human Resource will be determined through staffing norms and standards. The County should determine additional human resources required, for optimal norms, based on local peculiarities. JUSTIFICATION: Human resource needs are specific, based on actual workload and disease burden, and so cannot be appropriately planned for at the national level. However, a minimum staffing norm can be defined, based on expected functions and disease burden. This ensures equity in distribution of human resource for health. Additional human resource for health above these minimum norms would then be negotiated on a County by County basis.

POSITION 18: County level policy frameworks to implement the national level policy: The

National Government should coordinate and work with the Counties to develop County Health Strategies and Investment Plans for the County that will outline outcomes the County will strive to achieve in the Medium Term (5 years), and the priority investments it will need to put in place to achieve these outcomes. These Health Strategies customised from and be aligned to the overall Kenya Health Policy, and National Health Strategic plan. JUSTIFICATION: A clear medium term approach is needed for each County, to guide health investments and alignment to national health priorities. This should be informed by the health priorities of the County, and the Kenya Health Policy and Strategy.

POSITION 19: Annual work plans, and County level health sector budgets: Each County

should develop Comprehensive Health Sector Annual work Plans, which highlight priorities to be implemented with available resources they will have from their own sources, partners, and support from the National Government. The National Government will build the capacity of the counties in planning and budgeting. JUSTIFICATION: Financing for County activities will be sourced from different sources – County own resources, National Government, NGO are operating in the County, donors, and the private sector. A Comprehensive Health annual

Page 26 of 44

work Plan would bring all sources of funding to finance defined County priorities in a coordinated manner.

POSITION 20: Affirmative action programs and target Counties: Counties should prioritize

and develop disaggregated planning and resource allocation mechanisms to provide access and use of services by vulnerable populations within the County, particularly those not accessing / using health care due to gender, age, poverty, culture geographical or minorities and other vulnerabilities. The National Government will guide Counties in their planning, supervision and monitoring processes on how this will be achieved including the use of the Equalization Fund. JUSTIFICATION: Putting in place affirmative action programs enables indigent, and marginalised populations access and use services they require, and so improve on equitable use of resources available.

4.2.2 Cross-county and multi government level health functions

POSITION 21: Type and classification of cross-County health issue: Service delivery for Public Health programs by Counties that have a major public good element and those for whom the Country is internationally bound to address should remain financed and coordinated by the National Government.

JUSTIFICATION: Most public health programs have a strong element of a public good – benefits accrued are not limited to the County / individual, but spread across a wide population including across County borders. It is practical that, for such services where benefits have a more national outlook, coordination of their delivery should be handled by the National Government, as it would not be practical for a County to finance such services that end up benefiting many persons beyond the specific County. Examples of such programs are immunization services, emergency / disaster management, Polio control, and TB Control.

POSITION 22: Management and implementation of cross-County Public health program issues: National Government should be responsible for planning guidelines and target setting, resource mobilization, financing of commodities, and training of staff supporting provision of public health programs, while the County Government will be responsible for work planning, provision of staff, and physical infrastructure for the same. Operations, logistics and equipment will be a shared responsibility between National, and County Governments.

JUSTIFICATION: The proposed sharing of responsibilities is based on the comparative advantages of the National, and County Governments and recognises Constitutional mandates.

Page 27 of 44

POSITION 23: Inter-government response to health issue: Both National Government and Counties should plan for, and make available resources to address emergencies, disasters, and humanitarian activities within the Kenya Health policy .

JUSTIFICATION: Disease outbreaks, emergencies, disasters and other humanitarian needs can transverse county boundaries, and hence would call for a coordinated response across Counties. Adequate preparation and response for such will be needed, under guidance of the National Government, to mitigate the impacts of these events.

4.2.3 County Health Facilities, Assets and Liabilities POSITION 24: The standards required for hiring of health professionals at the County: Health

Workforce at the County should be hired at the County level in line with the standards and norms set by the National Government.

JUSTIFICATION: Health workforce is dynamic and unique, with lack of retention incentives especially in hard to reach areas a key problem. Affirmative action programs are needed to recruit, and sustain critical numbers of health workers across the country. Standardized staffing norms ensure Counties are recruiting competent and appropriately skilled staff, in numbers that ensure equity in distribution across the Country. Ensuring availability of a minimum capacity in each County should be a priority for national, and county Governments.

Position 25: Accreditation and licensing of health facilities: an accreditation of health providers and facilities will be done in accordance to the framework which will be provided to protect health and safety.

POSITION 26: Minimum working conditions and terms of service: The current conditions and terms of service for human resources in the health sector, who will be carrying out similar functions as before, should continue to apply. The National Government will define conditions, and terms of service for new positions being created. Additionally, incentives to attract and retain required human resources for health will be provided by the Counties, particularly those in marginalised regions

JUSTIFICATION: Putting in place new terms of service for positions that are not affected may lead to legal implications, which may interrupt delivery of services unnecessarily. Counties in disadvantaged areas will be receiving funds from the equalization fund, which they can use in improving working conditions, and attracting required human resources.

POSITION 27: Inventory of all assets within health sector and their current location within counties: The National Government should undertake a comprehensive inventory of all existing assets in the counties, to determine the number and the

Page 28 of 44

physical status, before transferring these to the Counties. These assets include human resources, physical infrastructure, medical and non medical equipment, plus existing supplies of medical products, vaccines and supplies. Before assets are transferred to the Counties, National Government will first verify the assets (number, the physical status) as documented by the inventory process, before endorsing the transfer using the agreed legal documentation. Asset transfer should be on an ‘as is’ basis, and includes all assets, irrespective of their state of functioning.

JUSTIFICATION: It is envisaged that there are functions transferred from the national to county governments. This will necessitate commensurate transfer of capacities including: human resources, physical infrastructure, medical and non medical equipment, plus existing supplies of medical products, vaccines and supplies and hence establishment of inventory is necessary. Assets transferred on an ‘as is’ basis, as the Constitution directs ALL, not just FUNCTIONAL assets be transferred. National and County Governments will need to be aware of and agree on assets that exist at the Counties to enable them plan their respective activities.

POSITION 28: Liquidation of liabilities: The National Government should assist, based on its capacity, to liquidate any liabilities at the point of transfer. A legal mechanism will be created which will allow County and National Governments to delegate any responsibility in this regard back and forth by mutual agreement.

JUSTIFICATION: This should provide a safety net for the Counties, allowing the National Government to support them execute any competencies they are not yet capable of handling.

4.2.4 Managing shared responsibilities on Human Resource management between National and County Governments

POSITION 29: Responsibilities of National, and County Governments in Human Resource Management: The National Government should be responsible for Development of minimum norms, elaboration of schemes of service (with the Public Service Commission), provision of pre and in service training, monitoring of sub specialized skills and development of guidelines for supervision and management of skilled human resources for the health sector. The County Governments will, on the other hand, be responsible for recruitment, deployment, management of human resources for health, personnel emoluments of staff, and provision of incentives for marginalised areas as guided by National legislation. The Health Sector will transfer existing staff to Counties, based on the agreed Government – wide terms and conditions of transfer of Human Resources.

JUSTIFICATION: The Constitution mandates the Counties, and the Public Service Commission to be responsible for recruitment, and management of schemes of service for public servants. The National Government (Health Ministry) through national legislation needs to provide norms, and standards against which staff

Page 29 of 44

are recruited, and monitored as part of its policy function. However, the Health workforce is dynamic and unique, with lack of retention incentives especially in hard to reach areas a key problem. Affirmative action programs are needed to recruit, and sustain critical numbers of health workers across the country. Standardized staffing norms and job descriptions ensure Counties are recruiting competent and appropriately skilled staff, in numbers that ensure equity in distribution across the Country. Ensuring availability of a minimum capacity in each county should be a priority for national, and county Governments.

POSITION 30: Regulation of the Health Workforce: The National Government should work in consultation with the County Governments to establish a broad legal framework for management of human resources for health within an updated health legal framework.

JUSTIFICATION: Under the current arrangements health care provision is regulated by the Public Health Act together with several Acts responsive to specific professional needs in the sector. There are inconsistencies and dissonance across these Acts, with the conflicting triad of policy making, provision and regulatory function of the Ministry. Incorporating this within the new Health Act ensures it is harmonized with other provisions of Health legislation.

4.2.5 Management of Health Commodities at the County POSITION 31: Levels of maintenance of medical products and technologies in the various

health facilities: Counties should put in place systems to plan, and monitor supplies of medical products and supplies, in a manner that eliminates stock outs due to system inefficiencies. The National Government will provide Counties with the guidelines on how to monitor this.

JUSTIFICATION: Stock outs of medical products and technologies should not occur, if such supplies exist in the country. Inefficiencies due to supply delays, or poor procurement practices negatively affect services, denying the client basic services. Planning and monitoring of this enables close follow up, to ensure it is not occurring.

POSITION 32: Management of procurement of Medical Products and Technologies: Centralized procurement mechanisms should be used by National and County Governments, to maximise quality assurance and economies of scales. Procurement essential medicines and medical supplies should be the responsibility of the National Government, while for other medical products and technologies should be responsibility of the county Governments, using devolved funds. The health sector recognises the role of Mission for Essensial Medicines (MEDS) in commodity management and quality assurance of medical commodities. JUSTIFICATION: National Government support is aimed at ensuring essential commodities and supplies are available, when and where needed, of the right

Page 30 of 44

qualities, and pricing. Pre-qualification of suppliers that meet these needs allows faster procurement processes. Centralized procurement represents best practice internationally for procurement of medicines and supplies, as this ensures the above. This is so in developed, and developing countries, where centralized procurement and distribution processes are utilized. Resource and efficiency savings will be attained in this way. Counties would receive their funds, in the spirit of the constitution, but use centralized procurement systems in their purchases.

Position 33: The role of Kenya Medical Supplies Agency(KEMSA): KEMSA should be the

point of first call for Medical products and Technologies by both the National, and County Governments. KEMSA should establish decentralized units to facilitate County procurement processes. Where KEMSA is not able to supply required medical products and technologies, other centralized procurement mechanisms should be used, using mechanisms defined in National legislation.

JUSTIFICATION: KEMSA at present has the statutory mandate to manage procurement, warehousing, and distribution of medical products and supplies. However, limiting purchases to one single source introduces monopoly inefficiencies. Placing an option of other accredited centralized suppliers in case of failure to deliver introduces competition, to ensure efficiency and effectiveness in KEMSA functioning.

POSITION 34: Procurement process by County Governments: County Government should

institute demand driven procurement of Medical Products and technologies (pull system) and appropriate use. Annual Procurement Plans based on this demand driven determination of needs will be included in their Health Annual Work Plans, to guide centralized planning for procurement, warehousing, and distribution through KEMSA. The National Government should support the County Governments build their capacity in demand driven procurement, and define Essential Medicine Lists against which procurements can be made. JUSTIFICATION: Having needs based planning for procurements using standard guideline and appropriate use of drugs allows better match between the needs of the County, and what is supplied.

POSITION 35: Minimum inventory standards for Medical Products and Technologies: County Governments will ensure inventories for Medical products and Supplies are well kept, and up to date. National Government will provide guidelines on appropriate inventory management.

JUSTIFICATION: Proper inventory management is critical to ensuring information on medical products and supplies status is always available, and up to date.

Page 31 of 44

4.2.6 Planning, budgeting and M&E at national and county levels for the health sector

POSITION 36: Health Strategic direction: The National Government will provide guidance to Counties on policy and strategy focus in Health.

JUSTIFICATION: The Constitution mandates the National Government to define long and medium term direction for Health, which will then guide Counties in elaborating their own Health Strategic directions.

POSITION 37: Coordination mechanisms joint planning, budgeting and reporting: The proposed County Health Management Team will coordinate development of County Health Plans budgets and reports, incorporating activities from all sub county units and partners operating in the County. These should be consolidated into the overall County plans, budgets and reports. The National Government will build the capacity of the proposed County Health Management Team in this regard.

JUSTIFICATION: The County Health focus should be a part of the overall development focus for the Country, and so be included in the overall Country development plans budgets and reports.

POSITION 38: Development of national and county level disaggregated indicators for reporting: The County Health Management Teams should routinely report on Health Status to the County Executive, and the National Government guided by the Monitoring and Evaluation framework of the Health Sector. The National Government should build the capacity of the County Health Management Team to collect, analyse and use the health information they have.

JUSTIFICATION: A harmonized M&E framework for the sector allows better follow up, support, and cross County comparison of performance. The Sector M&E framework ensures a comprehensive assessment of achievement, and reasons for achievement. This would enable the Counties put in place needed corrective measures to address their health challenges. Additionally, it also allows the Country provide information on international health reporting obligations, for example to the World Health Assembly, or specific partner national reporting requirements

POSITION 39: Efficiency and effectiveness of technical assistance/capacity building to county government: The National Government will regularly monitor, and report on requirement/demands, efficiency and effectiveness of technical assistance / capacity building provided to the County Governments.

JUSTIFICATION: Capacity building and Technical Assistance (TA) can be disruptive, if not demand driven, and of good quality. Regular follow up of impact of such TA / capacity building is needed, to further improve on the quality of support provided by the National Government.

Page 32 of 44

4.2.7 Merger of ministries and other related services

POSITION 40: Status of a Health Ministry: All functions relating to stewardship of Health at the National level should be brought together under one ministry responsible for Health and all health related functions currently under other ministries.

JUSTIFICATION: The new constitution places a limit on the total number of Ministries in the Government, which calls for rationalization in creation of Ministries. In addition the current global and Country paradigm for adequate Health Stewardship shifts focus from a Medical approach to health. This prioritizes a Ministry of Health focus on provision of health care, towards a comprehensive look at health and its determinants. This is to be elaborated in the Country’s new Comprehensive National Health Policy.

POSITION 41: Structure and functioning of the Health Ministry: The resultant Health Ministry will be structured based on the different functions that will be outlined in the Policy and Strategy for health sector. A Director General of Health should provide overall technical guidance and coordination of Health. A functional review will be undertaken to determine the structure and staff establishment of the health ministry at the national level .

JUSTIFICATION: Broader management of Health will require adequate stewardship of the health agenda, which is not limited to health care provision as the current Ministry structures are.

4.2.8 Health sector stakeholder partnership structures/frameworks POSITION 42: The proposed roles for all stakeholders in the health sector: The National and

County Governments should establish and maintain health sector dialogue and coordination frameworks amongst relevant arms of Government and other stakeholders. These should be built around principles of Aid Effectiveness, to ensure Efficiency and effectiveness in health care delivery. The National legislation should define frameworks for this coordination, to guide Counties in applying them.

JUSTIFICATION: The Health Ministries have been applying these principles since 2006 in a formal manner, leading to better sector coordination, and more comprehensive outcomes and impact as seen with improving health indicators and state of health in the country. Additionally, available resources are able to achieve more when support is coordinated, as different actor activities start to better-complement each other, as opposed to duplication of efforts. Finally, bringing together the wider health sector under one Ministry, plus coordination with other independent, health related sectors, such as education, require strong health sector coordination mechanisms, both at National and County levels.

Page 33 of 44

POSITION 43: The nature and scope of joint planning, budgeting at the national level: The National Government, through the Ministry responsible for Health will coordinate the annual joint setting of priorities, baselines and targets on health and health related matters to be used for both planning and budgeting/resource mobilisation and allocation by both the national, county governments and other stakeholders towards the achievement of the overall health goals. The National Government will develop and facilitate application of joint planning and budgeting framework/guidelines for both National, and County Governments and other stakeholders.

JUSTIFICATION: The health sector operates under a single sector policy and medium term strategy aligned to GOK planning cycle which is an important pre-requisite to continue building of a government-led and sustained partnership with the various stakeholders. Clear frameworks are required to guide the joint planning and budgeting activities, which will ensure active stakeholder participation at all levels of Government

POSITION 44: Monitoring, evaluation and reporting by Non State actors in the health sector: All stakeholders in the health sector will report on their activities at both National, and County Government levels as per the National and County planning cycles. Annual Joint Reviews involving all stakeholders should be held by both County, and National Governments. National legislation will provide guidance to non state actors, partners, and Counties on how these should be conducted and reporting done.

JUSTIFICATION: Joint review of performance by both state, and non state stakeholders has proved critical in ensuring mutual accountability, and focusing of efforts towards defined priorities.

POSITION 45: Managing Public Private Partnerships in the health sector: Frameworks to guide partnerships with non state health service providers should be clearly elaborated, and integrated into the overall health sector policy, strategy, and legal frameworks.

JUSTIFICATION: Non state service providers are a significant source of health services, particularly in urban areas (private for profit), and in hard to reach areas (private not for profit). Mechanisms for ensuring their health services are complementary to the public health services need to be clearly defined, so the National and County governments are guided on how to engage with them. Financing and regulation are also core elements of Public Private Partnerships. Tapping of finances, skills and other resources will be enhanced.

POSITION 46: Managing stakeholder partnerships in the health sector: The National Government will lead the process of defining partnership instruments that outlines obligations of different health sector stakeholders – National, and County Governments, non state service providers, and development partners. This process should be participatory, and focus on defining obligations guided by principles of good partnerships in health.

Page 34 of 44

JUSTIFICATION: Current experience with a partnership instrument – the Health Sector Code of Conduct – shows when properly applied, it facilitates better coordination of the sector support. Allowing each County to develop its own partnership instrument is an unnecessary burden, as the partners, and principles are similar.

POSITION 47: Financing of Healthcare: The National Government will lead the process of developing appropriate mechanisms for financing of health services that will ensure that no person is denied access to quality healthcare and emergency treatment in both public and private health facilities. The key mechanisms will be included in the Kenya Health Policy and the overall policies and strategies on healthcare financing.

JUSTIFICATION: Developing mechanisms for the financing of healthcare will be critical in providing guidance to all providers on how to deal with people who may be requiring care but are unable to pay. The mechanisms will also give guidance on how funds from various will be channelled to the health providers and the role of the counties, with the overall aim of achieving efficiency in the delivery of services.

Page 35 of 44

5 SECTION 5: CONCLUSION The positions presented herewith have been reached at after a careful review and consideration of:

a) the provisions, and intentions of the new Constitution; b) lessons learnt from health sector reform on decentralization that the health sector has

been undertaking over the years; c) lessons learnt from other countries that have gone similar direction of devolving health

services to lower governments and d) The need to support the efficient and effective implementation of the new Constitution

especially implementation of rights based approach to the provision of health services and devolution of health services to County governments.

It is our hope that the implementation of these positions will be in line with spirit in which the new Constitution has been developed. We are of the belief that these positions will bring the governance of the health services close to the people, improve efficiency and effectiveness of the delivery of health services to the population, increase accountability in the allocation and use of resources allocated for health and addressing the existing inequalities in accessing and utilisation of quality health services. The position paper is, therefore, submitted to the Constitution Implementation Taskforce for your review, approval and any guidance you may wish to give.

Page 36 of 44

6 REFERENCE INFORMATION

6.1 Key definitions Abortion: Termination of a pregnancy before it is viable as an independent life outside of the womb. This can occur spontaneously, or be induced by external actions. Current medical expertise in the country can sustain a viable life outside the womb from 24 weeks of gestation. As medical expertise improves, this should reduce further. Unsafe abortion remains a major cause of maternal mortality.

Ambulatory: A condition or a procedure, not requiring admission to a hospital. These are managed on an outpatient basis.

Disease: Any condition that causes pain, dysfunction, distress, social problems, and / or death to the person afflicted, or similar problems for those in contact with the person. It may be caused by external factors, such as infectious diseases, or by internal dysfunctions, such as cancers. Diseases usually affect people not only physically, but also emotionally, as contracting and living with many diseases can alter one's perspective on life, and their personality.

Emergency: Any event / crisis that exceeds the community’s or an individual’s ability to respond

Emergency treatment: Health care services necessary to prevent and manage the damaging health effects from an emergency situation. It involves services across ALL aspects of health care services, and includes:

a. first aid treatment of ambulatory patients and those with minor injuries;

b. public health information on emergency treatment, prevention, and control; and

c. Administrative support including maintenance of vital records and providing for a conduit of emergency health funds across Government.

Emergency care involves arrangements for transfer to clients once the emergency nature of the service is stabilized. Execution of these transfer arrangements ends the emergency phase of health care.

Health: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity2 .

Health care professionals: The workforce that delivers the defined Health care services. The workforce includes all those whose prime responsibility is the provision of health care services, irrespective of their organizational base (public, or non-public).

Health Care Services: The prevention and management of disease, illness, injury, and other physical and mental impairments in individuals delivered by health care professionals through the health care system and can either be routine health services, or emergency health services.

Health System: The mechanism to deliver quality health care services to all people, when and where they need them. Humanitarian actions: All actions to mitigate effects of an emergency. These include emergency health services.

2Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, and 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

Page 37 of 44

Human Resource for Healthhe stock of all individuals engaged primarily in the improvement of the health of populations. The public health workforce includes those primarily involved in protecting and promoting the health of whole or specific populations, as distinct from activities directed to the care of individuals.

Illness: A state of poor health or when conditions of health are not fulfilled.

Injury: Physical damage to a person.

Level of health care delivery: Description of the organization of health services delivery, in a rationalized manner. Four levels of service delivery are defined for Kenya3:

Level 1: Community Based Health Services. Health Care activities focused on ensuring individuals, households and communities carry out appropriate healthy behavior, and recognize signs and symptoms of conditions that need to be managed at other levels of the system.

Level 2: Primary care based health services. Health care activities focused on ensuring provision of disease prevention, basic outpatient medical and surgical care services, limited inpatient services for emergency clients awaiting referral, clients for observation, normal delivery services, routine laboratory services for common conditions, plus coordination of level 1 services within its jurisdiction. They include dispensaries, Health Centers, Maternity homes, and clinics.

Level 3: County Referral Services. Health activities focused on provision of appropriate medical care on an inpatient basis, and primary referral functions for the level 1 – 2 service levels in their jurisdiction. They constitute the primary referral unit for health care delivery system, as they complement the lower level units by ensuring comprehensive delivery of health care. They include district hospitals, private hospitals. All the level 4 units in a county together constitute the county referral system.

Level 4: National Referral Services. Health activities focused on specialized medical care services, training facilities for health workers, and internship centers. They constitute the national referral system for health care delivery system, given the national nature of their functions (training, internship, specialized care). They include provincial general hospitals, high volume district hospitals (6 in total), large private hospitals, general referrals (KNH, MTRH), and specialized referrals (Spinal Injury, Mathare hospitals).

Medical Care Services: The management of disease, illness, injury, and other physical and mental impairments in humans. This involves diagnosis, treatment and rehabilitation of persons, following a disease, illness, injury or other impairment.

Non-State Actors: Individuals, or institutions whose primary purpose are in provision of Health Services, but are not a part of the State. They include service providers (for profit and not for profit), Health Civil Society organizations, NGO’s and their related management systems.

Post delivery period: This represents the 6 weeks following delivery. It corresponds with the post partum period.

Public Health Services: The health care services concerned with the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals and are concerned with threats to the overall health of a community.

Referral: The process by which a given level of health services that has inadequate capacity to manage a given health condition or event, seeks the assistance of a higher level of health care delivery to guide, or take over its management. It ensures establishment of efficient health service delivery system linkages across levels of care that ensure continuity of care, for effective

3 Draft Comprehensive National Health Policy, 2011 – 2030.

Page 38 of 44

management of health needs of the population in Kenya. It involves movement of clients, expertise, specimens, or client information4.

Referral health services: The health care services whose function is specifically to manage, or facilitate the referral process.

Reproductive health: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. It includes the right of men and women to be informed [about] and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of birth control which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant5.

Routine Health Services: Health care services necessary to prevent and manage the damaging health effects from non emergency situations. It involves services across ALL aspects of health care services.

Trained Health professional (in the context of provision of legal termination of pregnancy): A health professional, with formal medical training at proficiency level of a Medical Officer (doctor), nurse midwife, or clinical officer who has been educated and trained to proficiency in the skills needed to manage uncomplicated abortion and post abortion care and in the identification, management and referral of abortion related complications in women and family. Such a health professional should have a valid license from the Medical and Dental practitioners Council to practice, and providing the service from a legally recognized health facility with an enabling environment consisting of the minimum human resources, infrastructure, commodities and supplies for the facility as defined in the health sector norms and standards.

Unsafe abortion: A procedure carried out by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both6

4Ministry Referral Strategy, 2009 5United Nations Department of Public Information. International Conference on Population and Development Program of Action. DPI/1618/POP--March 1995 6World Health Organization. (2004). "Unsafe abortion: global and regional estimates of unsafe abortion and associated mortality in 2000"

Page 39 of 44

6.2 Referral Units distribution

6.2.1 National referral Units Current Unit name Type of referral services

Kenyatta National Hospital National Referral Services– General Hospital

Moi Teaching and Referral Hospital National Referral Services– General Hospital

Mathari Hospital National Referral Services - Mental Health Hospital

Spinal Injury Hospital National Referral Services -Spinal injury hospital

Pumwani hospital National Referral Services -Obstetrics/Gynecology hospital

Nyeri Provincial General Hospital National Referral Services - Central region hospital

Coast Province General Hospital National Referral Services - Coast region hospital

Embu Provincial General Hospital National Referral Services - eastern region hospital

Nakuru Provincial General Hospital National Referral Services - Rift Valley region hospital

Kakamega Provincial General Hospital National Referral Services - Western region hospital

New Nyanza Provincial Gen. Hospital National Referral Services - Nyanza region hospital

Garissa Provincial General Hospital National Referral Services - North eastern region hospital

National Quality Control Laboratories National referral Services – Laboratory Quality Control

National Public Health Laboratory National referral Services –Public Health laboratory

Government Chemist National referral Services – Chemical analyses

National Blood Transfusion Services National referral Services – Blood transfusion

Radiation Protection Board National referral services – radiation protection

Kenya Medical Research Institute National referral services - research

Page 40 of 44

6.2.2 County Referral hospitals County Current facility name Type of facility

County Current facility name Type of facility

1.Kiambu Thika Level 5 Hospital County Hospital - Kiambu

16.Embu Kianjokoma Sub-District Hospital County Hospital - Embu

Ruiru Sub-District Hospital County Hospital - Kiambu

Runyenjes District Hospital County Hospital - Embu

Kiambu District Hospital County Hospital - Kiambu

Siakago District Hospital County Hospital - Embu

Kihara Sub-District Hospital County Hospital - Kiambu

Ishiara Sub-District Hospital County Hospital - Embu

Igegania Sub-District Hospital County Hospital - Kiambu

17.Kitui Kitui District Hospital County Hospital - Kitui

Gatundu District Hospital County Hospital - Kiambu

Katulani Sub-District Hospital County Hospital - Kitui

Nyathuna Sub-District Hospital County Hospital - Kiambu

Ikanga Sub-District Hospital County Hospital - Kitui

Tigoni District Hospital County Hospital - Kiambu

Kanyangi Sub-District Hospital County Hospital - Kitui

2.Murang'a Murang'a District Hospital County Hospital - Murang'a

Kauwi Sub-District Hospital County Hospital - Kitui

Muriranjas District Hospital County Hospital - Murang'a

Mwingi District Hospital County Hospital - Kitui

Kangema Sub-District Hospital County Hospital - Murang'a

Migwani Sub-District Hospital County Hospital - Kitui

Kirwara Sub-District Hospital County Hospital - Murang'a

Kyuso Sub-District Hospital County Hospital - Kitui

Maragwa District Hospital County Hospital - Murang'a

Tseikuru Sub-District Hospital County Hospital - Kitui

3.Kirinyaga Kerugoya District Hospital County Hospital - Kirinyaga

Nuu Sub-District Hospital County Hospital - Kitui

Kianyaga Sub-District Hospital County Hospital - Kirinyaga

Mutitu Sub-District Hospital County Hospital - Kitui

Kimbimbi Sub-District Hospital County Hospital - Kirinyaga

18.Machakos Machakos Level 5 Hospital County Hospital - Machakos

4.Nyeri Mt. Kenya Sub-District Hospital County Hospital - Nyeri

Kangundo District Hospital County Hospital - Machakos

Karatina District Hospital County Hospital - Nyeri

Kathiani Sub-District Hospital County Hospital - Machakos

Mukurwe-ini Sub-District Hospital County Hospital - Nyeri

Mwala Sub-District Hospital County Hospital - Machakos

Othaya District Hospital County Hospital - Nyeri

Matuu Sub-District Hospital County Hospital - Machakos

5.Nyandarua Nyahururu District Hospital County Hospital - Nyandarua

19.Makueni Makueni District Hospital County Hospital - Makueni

Ol'kalou District Hospital County Hospital - Nyandarua

Matiliku District Hospital County Hospital - Makueni

Engineer District Hospital County Hospital - Nyandarua

Sultan Hamud Sub-District Hospital County Hospital - Makueni

6.Mombasa Port Reitz District Hospital County Hospital - Mombasa

Makindu District Hospital County Hospital - Makueni

Tudor Sub-District Hospital County Hospital - Mombasa

Kibwezi Sub-District Hospital County Hospital - Makueni

Likoni Sub-District Hospital County Hospital - Mombasa

Nunguni Sub-District Hospital County Hospital - Makueni

7.Kwale Msambweni District Hospital County Hospital - Kwale

Mbooni District Hospital County Hospital - Makueni

Kinango District Hospital County Hospital - Kwale

Tawa Sub-District Hospital County Hospital - Makueni

Kwale District Hospital County Hospital - Kwale

Kisau Sub-District Hospital County Hospital - Makueni

8.Kilifi Kilifi District Hospital County Hospital - Kilifi

20.Turkana Lodwar District Hospital County Hospital - Turkana

Malindi District Hospital County Hospital - Kilifi

Lopiding District Hospital County Hospital - Turkana

Mariakani District Hospital County Hospital - Kilifi

Lokitaung Sub-District Hospital County Hospital - Turkana

Jibana Sub-District Hospital County Hospital - Kilifi

21.West Pokot Kapenguria District Hospital County Hospital - West Pokot

Bamba Sub-District Hospital County Hospital - Kilifi

Chepareria Sub-District Hospital County Hospital - West Pokot

9.Tana River Hola District Hospital County Hospital - Tana river

Kacheliba Sub-District Hospital County Hospital - West Pokot

Page 41 of 44

Ngao District Hospital County Hospital - Tana river

Sigor Sub-District Hospital County Hospital - West Pokot

10.Lamu Lamu District Hospital County Hospital - Lamu

22.Samburu Maralal District Hospital County Hospital - Samburu

Faza Sub-District Hospital County Hospital - Lamu

Baragoi Sub-District Hospital County Hospital - Samburu

Mpeketoni Sub-District Hospital County Hospital - Lamu

23.Trans Nzoia Kitale District County Hospital - Trans Nzoia

11.Taita/ Taveta Wesu District Hospital County Hospital - Taita/Taveta

Saboti Sub-District Hospital County Hospital - Trans Nzoia

Wundanyi Sub-District Hospital County Hospital - Taita/Taveta

Endebess Sub-District Hospital County Hospital - Trans Nzoia

Moi (Voi) District Hospital County Hospital - Taita/Taveta

24.Uasin Gishu Huruma District Hospital County Hospital - Uasingishu

Taveta District Hospital County Hospital - Taita/Taveta

Ziwa Sub-District Hospital County Hospital - Uasingishu

Mwatate Sub-District Hospital County Hospital - Taita/Taveta

25.Elgeyo/ Marakwet Iten District Hospital County Hospital - Keiyo

Mwambirwa Sub-District Hospital County Hospital - Taita/Taveta

Tambach Sub-District Hospital County Hospital - Keiyo

12.Marsabit Marsabit District Hospital County Hospital - Marsabit

Kamwosor Sub-District Hospital County Hospital - Keiyo

Moyale District Hospital County Hospital - Marsabit

Kocholwo Sub-District Hospital County Hospital - Keiyo

13.Isiolo Isiolo District Hospital County Hospital - Isiolo

Kaptarakwa Sub-District Hospital County Hospital - Keiyo

Garbatulla District Hospital County Hospital - Isiolo

Chebiemit District Hospital (Marakwet) County Hospital - Keiyo

14.Meru Meru Level 5 Hospital County Hospital - Meru

Tot Sub-District Hosptial County Hospital - Keiyo

Giaki Sub-District Hospital County Hospital - Meru

26.Nandi Kapsabet District Hospital County Hospital - Nandi

Timau Sub-District Hospital County Hospital - Meru

Nandi Hills District Hospital County Hospital - Nandi

Kibirichia Sub-District Hospital County Hospital - Meru

Meteitei Sub-District Hospital County Hospital - Nandi

Githongo Sub-District Hospital County Hospital - Meru

Kaptumo Sub-District Hospital County Hospital - Nandi

Kinoro Sub-District Hospital County Hospital - Meru

Chepterwai Sub-District Hospital County Hospital - Nandi

Mikumbune Sub-District Hospital County Hospital - Meru

27.Baringo Kabarnet District Hospital County Hospital - Baringo

Kanyakine Sub-District Hospital County Hospital - Meru

Marigat Sub-District County Hospital - Baringo

Mutuati Sub-District Hospital County Hospital - Meru

Chemolingot Sub-District Hospital County Hospital - Baringo

Nyambene District Hospital County Hospital - Meru

Kapedo Sub-District Hospital County Hospital - Baringo

Muthara Sub-District Hospital County Hospital - Meru

Eldama Ravine District Hospital County Hospital - Baringo

Mikinduri Sub-District Hospital County Hospital - Meru

28.Laikipia Nanyuki District Hospital County Hospital - Laikipia

Mbeu Sub-District Hospital County Hospital - Meru

Doldol Sub-District Hospital County Hospital - Laikipia

Miathene District Hospital County Hospital - Meru

Rumuruti Sub-District Hosptial County Hospital - Laikipia

15.Tharaka-Nthi Chuka District Hospital County Hospital - Tharaka

Magutuni Sub-District Hospital County Hospital - Tharaka

Tharaka (Marimanti) District Hospital County Hospital - Tharaka

Kibunga Sub-District Hospital County Hospital - Tharaka

Page 42 of 44

County Current facility name Type of facility

County Current facility name Type of facility 29.Nakuru Annex Hospital Nakuru County Hospital - Nakuru

40.Homa Bay Homa-Bay District Hospital County Hospital - Homa Bay

Naivasha District Hospital County Hospital - Nakuru

Rangwe Sub-District Hospital County Hospital - Homa Bay Gilgil Sub District Hospital County Hospital - Nakuru

Ndhiwa Sub-District Hospital County Hospital - Homa Bay

Olenguruone Sub-District Hospital County Hospital - Nakuru

Rachuonyo District Hospital County Hospital - Homa Bay Molo Sub District Hospital County Hospital - Nakuru

Kabondo Sub-District Hospital County Hospital - Homa Bay

ElburgonNyayo Sub District Hospital County Hospital - Nakuru

Othoro Sub-District Hospital County Hospital - Homa Bay Bahati District Hospital County Hospital - Nakuru

Kandiege Sub-District Hospital County Hospital - Homa Bay

30.Narok Narok District Hospital County Hospital - Narok

Kendu Bay Sub-District Hospital County Hospital - Homa Bay Ololulung'a District Hospital County Hospital - Narok

Mbita Sub-District Hospital County Hospital - Homa Bay

Kilgoris District Hospital County Hospital - Narok

Ogongo Sub-District Hospital County Hospital - Homa Bay Lolgorian Sub-District Hospital County Hospital - Narok

Suba (Sindo) District Hospital County Hospital - Homa Bay

31.Kajiado Kajiado District Hospital County Hospital - Kajiado

Kisegi Sub-District Hospital County Hospital - Homa Bay Loitoktok Sub-District Hospital County Hospital - Kajiado

41.Migori Migori District Hospital County Hospital - Migori

Ngong Sub-District Hospital County Hospital - Kajiado

Karungu Sub-District Hospital County Hospital - Migori 32.Kericho Kericho District Hospital County Hospital - Kericho

Macalder Sub-District Hospital County Hospital - Migori

Londiani District Hospital County Hospital - Kericho

Kehancha District Hospital County Hospital - Migori Kipkelion Sub-District Hospital County Hospital - Kericho

Ntimaru Sub-District Hospital County Hospital - Migori

Fort-Ternan Sub-District Hospital County Hospital - Kericho

Isebania Sub-District Hospital County Hospital - Migori

Kapkatet District Hopsital County Hospital – Kericho

Roret Sub-District Hospital County Hospital – Kericho

Rongo Sub-District Hospital County Hospital - Migori

Sigowet Sub-District Hospital County Hospital - Kericho

33.Bomet Cheptalal Sub-District Hospital County Hospital - Bomet

Awendo Sub-District Hospital County Hospital - Migori Longisa District Hospital County Hospital - Bomet

42.Kisii Marani Sub-District Hospital County Hospital - Kisii

Sigowet Sub-District Hospital County Hospital - Bomet

Kisii Level 5 Hospital County Hospital - Kisii

Keumbu Sub-District Hospital County Hospital - Kisii

Ibeno Sub-District Hospital County Hospital - Kisii 34.Kakamega Navakholo Sub-District Hospital County Hospital - Kakamega

Nyamache District Hospital County Hospital - Kisii

Iguhu District Hospital County Hospital - Kakamega

Nyacheki Sub-District Hospital County Hospital - Kisii Shibwe Sub-District Hospital County Hospital - Kakamega

Gucha District Hospital County Hospital - Kisii

Malava District Hosptial County Hospital - Kakamega

Kenyenya Sub-District Hospital County Hospital - Kisii Lumakanda District Hospital County Hospital - Kakamega

Iyabe Sub-District Hospital County Hospital - Kisii

Matunda Sub-District Hospital County Hospital - Kakamega

Etago Sub-District Hospital County Hospital - Kisii Mautuma Sub-District Hospital County Hospital - Kakamega

Nduru Sub-District Hospital County Hospital - Kisii

Likuyani Sub-District Hospital County Hospital - Kakamega

43.Nyamira Nyamira District Hospital County Hospital - Nyamira Butere District Hospital County Hospital - Kakamega

Nyamusi Sub-District Hospital County Hospital - Nyamira

Manyala Sub-District Hospital County Hospital - Kakamega

Ekerenyo Sub-District Hospital County Hospital - Nyamira Matungu Sub-District Hospital County Hospital - Kakamega

Nyangena Sub-District Hospital County Hospital - Nyamira

35.Vihiga Vihiga District Hospital County Hospital - Vihiga

Manga Sub-District Hospital County Hospital - Nyamira

Page 43 of 44

36.Bungoma Bungoma District Hospital County Hospital - Bungoma

Esani Sub-District Hospital County Hospital - Nyamira Kimilili District Hospital County Hospital - Bungoma

Keroka District Hospital(Masaba) County Hospital - Nyamira

Naitiri Sub-District Hospital County Hospital - Bungoma

Ibacho Sub-District Hospital County Hospital - Nyamira Sirisia Sub-District Hospital County Hospital - Bungoma

Masimba Sub-District Hospital County Hospital - Nyamira

Webuye District Hospital County Hospital - Bungoma

Gesusu Sub-District Hospital County Hospital - Nyamira Bokoli Sub-District Hospital County Hospital - Bungoma

Kijauri Sub-District Hospital County Hospital - Nyamira

Mt. Elgon District Hospital County Hospital - Bungoma

44.Garissa Mbalambala Sub-District Hospital County Hospital - Garissa Cheptais Sub-District Hospital County Hospital - Bungoma

Iftin Sub-District Hospital County Hospital - Garissa

37.Busia Busia District Hospital County Hospital - Busia

Masalani District Hospital County Hospital - Garissa Khunyangu Sub-District Hospital County Hospital - Busia

Hulugho Sub-District Hospital County Hospital - Garissa

Teso District Hospital (Kocholia) County Hospital - Busia

Dadaab Sub-District Hospital County Hospital - Garissa Alupe Sub-District Hospital County Hospital - Busia

Modogashe District Hospital County Hospital - Garissa

Sio Port District Hospital County Hospital - Busia

45.Wajir Wajir District Hospital County Hospital - Wajir Port Victoria SDH County Hospital - Busia

KhorofHarar Sub-District Hospital County Hospital - Wajir

38.Siaya Siaya District Hospital County Hospital - Siaya

Bute District Hospital County Hospital - Wajir Yala Sub-District Hospital County Hospital - Siaya

Buna Sub-District Hospital County Hospital - Wajir

Ambira Sub-District Hospital County Hospital - Siaya

Habaswein Sub-District Hospital County Hospital - Wajir Bondo District Hospital County Hospital - Siaya

46.Mandera Mandera District Hospital County Hospital - Mandera

Got Agulu Sub-District Hospital County Hospital - Siaya

Lafey Sub-District Hospital County Hospital - Mandera Madiany Sub-District Hospital County Hospital - Siaya

Rhamu Sub-District Hospital County Hospital - Mandera

39.Kisumu Kisumu District Hospital County Hospital - Kisumu

Elwak Sub-District Hospital County Hospital - Mandera Nyahera Sub-District Hospital County Hospital - Kisumu

Takaba Sub-District Hospital County Hospital - Mandera

Victoria Sub-District Hospital County Hospital - Kisumu

47.Nairobi Mbagathi District Hospital County Hospital - Nairobi Miranga Sub-District Hospital County Hospital - Kisumu

Dagoretti Sub -District Hospital (Mutuini) County Hospital - Nairobi

Chulaimbo Sub-District Hospital County Hospital - Kisumu

Embakasi District Hospital County Hospital - Nairobi Kombewa Sub-District Hospital County Hospital - Kisumu

Kayole II Sub-District Hospital County Hospital - Nairobi

Nyando District Hospital County Hospital - Kisumu Muhoroni Sub-District Hospital County Hospital - Kisumu Masogo Sub-District Hospital County Hospital - Kisumu Ahero Sub-District Hospital County Hospital - Kisumu

Page 44 of 44

6.3 References iGovernment of Kenya, 2010.Report of the retreat for Permanent Secretaries/Accounting Officers on the Implementation of the Constitution, 17th – 18th September 2010 iiWorld Health Organization, 2007. Everybody’s business: Strengthening Health Systems to improve Health Outcomes. WHO’s framework for action. ISBN 978 92 4 159607 7 iiiGovernment of Kenya, 1994.Kenya Health Policy Framework. Ministry of Health ivGovernment of Kenya, 2010.Synthesis report of the review of the Kenya Health Policy Framework, 1994 – 2010.Ministry of Medical Services, and Ministry of Public Health and Sanitation. vGovernment of Kenya, 2010. Kenya Health Situation Analysis, trends and distribution, 1994 – 2010 and projections to 2030. Ministry of Medical Services, and Ministry of Public Health and Sanitation. viGovernment of Kenya, 2008.Presidential Circular number 1. Office of the President viiGovernment of Kenya, 2005.Kenya Health SWAp concept paper, October 2005. Ministry of Health viiiGovernment of Kenya, 2007. Health Sector Code of Conduct, August 2007. Ministry of Health ixGovernment of Kenya, 2011.National Health Accounts, 2009/10. Ministry of Medical Services and Ministry of Public health & Sanitation. xKOVNER, CHRISTINE T. PHD, et al, 2007. Newly Licensed RNs' Characteristics, Work Attitudes, and Intentions to Work. American Journal of Nursing, September 2007 - Volume 107 - Issue 9 - p 58-70 xiGovernment of Kenya, 2010.Kenya Pharmaceutical Sector Policy. Ministry of Medical Services xiiGovernment of Kenya, 2008. Health Information System Strategic Plan, 2008 – 2012. Ministry of Medical Services, and Ministry of Public Health & Sanitation. xiiiGovernment of Kenya, 2010.Knowledge Management Framework for Health in Kenya. Ministry of Medical Services, and Ministry of Public Health & Sanitation. xivGovernment of Kenya, 2006. Health Sector Joint Program of Work and Funding, 2006 – 2010. Ministry of Health xvWorld Health Organization, 2010.Framework for the Implementation of the Ouagadougou declaration on Primary Health Care and Health Systems in Africa. Regional Office for Africa. xviWorld Health Organization, 2008.The World Health Report, 2008 – primary health care (Now more than ever).World health Organization, Geneva. xviiWorld health Organization, 2001. Macroeconomics and Health: Investing in health for economic development. Report of the Commission on Macroeconomics and Health. World Health Organization, Geneva