Is Kenya’s health system ready for

devolved governance?

Aaron MulakiHealth Systems/Public Administration Advisor

June 20, 2014

Context

Kenya recently celebrated its first birthday in a devolved system of governance following the March, 2012 elections under 2010 constitution

Devolution in Kenya not new. False start in 1963 under majimbo followed by failures in other decentralization reforms

Devolution is pursued for technical, political, and financial reasons

In Kenya devolution of power seeks to correct historical injustices associated with centralized governance

Kenya’s devolution framework considered complex in scale and magnitude

New constitution progressive in bill of rights

Why devolve?

Principles-Democracy, separation of power, reliable resources, gender (Art 175, CoK)

Objectives (Art 174) Promoting democratic and accountable exercise of power Fostering national unity by recognizing diversity Enable self governance to the people Enhance participation of the people in the exercise of the powers and the state making

decisions for them Recognize the right of communities to manage their own affairs and to further their

development Promote social and economic development and the provision of proximate, easily

accessible services Ensure equitable sharing of national and local resources Facilitate the decentralization of state organs, their functions and services Enhance checks and balances and separation of power

Kenya’s devolution framework

Numerous reforms implemented with mixed results (e.g DHMTs)

Devolving health will improve efficiency, stimulate innovation, improve access and equity, and promote accountability and transparency

Schedule IV assigns policy, national referral facilities, capacity building to national government and service delivery to counties

Devolving health has had its fair share of challenges

Success on uptake of health function by counties is largely dependent on health system preparedness

Decentralization of health not new!

Assessing county health system readiness

Overview of Methodology

Examined variations in county revenue per capita

Assessed availability of health facilities

Assessment of 16 county level health input indicators based on the WHO building blocks under four categories;

Physical infrastructure and equipment; human resources for health; drug availability, organization of service delivery and governance

Data sources included: SARAM-Kenya Service Availability and Readiness Assessment Mapping (SARAM), a

census involving all health facilities in the country and management units Pets-Plus- a combination of Public Expenditure Tracking Survey and a Service

Delivery Indicator (SDI) survey that assesses overall service delivery performance of 294 public and nonprofit private health facilities and 1,859 health providers in Kenya

How was county health system readiness analyzed?

Results

Availability of health facilities

There is inequality in health facility distribution across 47 counties

Counties must make sure that their clients spend little time accessing a facility, and facilities must be able to handle as many case loads

• Half of counties have fewer than 2 health facilities per 10,000 people and 4.2 facilities per 100 square kilometers

• Mombasa and Nairobi have 134 and 124 per 100 sq kms, but have far fewer facilities per 10,000 (2.9 and 2,4 respectively)

• Bungoma and Busia have fewest facilities per 10,000 people but more facilities per 100 sq kilometers

• Kilifi, Mandera,Turkana, Wajir, Narok and Bomet have low number of facilities per 10,000 and low number of facilities per 100 sq kms

Performance on infrastructure and equipment poor

1. Percentage of primary care centers with an ante-natal(ANC) ward• Huge variations (8-85%)

2. Number of operating theatres per hospital• 0.09 to 2.33

3. Number of ambulances per hospital• 0.06 to 3.636

4. Number of KEPI refrigerators per maternal and child health unit• 1.13 to 3.87

5. Number of CD4 machines per facility with laboratories• 0 to 0.58

• Samburu is the only county that is in the top third for at least 4/5 indicators

• Isiolo, Narok, Kericho, Elgeyo Marakwet and Bungoma are the only counties that do not fall in the bottom third in any of the indicators

• Kirinyaga,Wajir, Kajiado consistently in the bottom third of all counties across all the indicators

Equipment/Infrastructure Availability

Human Resources for Health

Doctors per 10,000 people in the 47 counties ranges from (0) Mandera to (2) Nairobi benchmark is 3(MOH,2013b)

Higher densities for nurses between 0.9 per 10,000 (Mandera) to 11.8 per 10,000 (Isiolo)

Only 4 counties meet Kenya’s benchmark of 8.7 per 10,000.

Staff absenteeism• W.Pokot, Makueni have lowest

rates < 20% • Nyamira, Siaya, Transzoia,

Uasin Gishu >40%

Diagnostic Capacity• Makueni, Nairobi, Mombasa

>80% • Homabay, Kitui, Uasin Gishu,

Kilifi

Quantities Quality

Availability of drugs

• 34-63% of counties have maternal health tracer drugs but 18-39% of child health tracer drugs available

• Large disparities in the availability of first line HIV drugs (0-50%)

• Kisumu, Kisii, Vihiga, and Siaya consistently top third in drug availability

• Transzoia, E-Marakwet, Nandi, Nyeri & T.River bottom

1. 11 maternal health tracer drugs2. 11 child health tracer drugs3. First-line drugs for HIV4. ACT, first line treatment for

malaria5. 4FDC, intensive treatment for

tuberculosis 6. Metformin, preferred OGLA

treatment for diabetes

Drug types Average availability

Revenue per capita (RPC) ranges significantly by county. Mandera has 6 times the per capita of Nairobi

RPC sometimes corresponds to counties’ performance across the 16 indicators e.g Nairobi has the least RPC and is in the bottom third of counties for 9/16 indicators. Machakos, Narok, Nakuru, Kericho, Siaya, Kakamega & Makueni

with below average RPC preform better than other counties Counties with above average RPC that are in the bottom third for

at least 8/16 indicators

RPC not necessarily linked to county health system readiness

County readiness and Revenue

Conclusion and Recommendations

1. Focus on relatively low-performing counties 2. Target weak areas across all counties3. Provide counties with norms and standards for benchmarking

• There is great variability in county health system readiness • About nine counties preform consistently poorly-bottom third across

the 16 indicators• Counties that performed relatively well across the indicators may still

have inadequate inputs

www.healthpolicyproject.com

Thank You!

The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with CEDPA (CEDPA is now a part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA).