KENYA HEALTHCARE FEDERATION COVER PAGE (Branding to be discussed
BASELINE STUDY ON HEALTHCARE DELIVERY IN KENYA
TABLE OF CONTENTS
EXECUTIVE SUMMARY ............................................................................................................................ ii 1.0 INTRODUCTION ................................................................................................................................. 1 1.1 Overview of the Health System in Kenya ...................................................................................... 1 1.2 Rationale for the Baseline Survey ................................................................................................. 7 2.0 STUDY APPROACH AND METHODOLOGY ......................................................................................... 9 2.1 Approach ....................................................................................................................................... 9 2.2 Methodology................................................................................................................................. 9 3.0 BASELINE SURVEY FINDINGS ........................................................................................................... 12 3.1 Physical and Human Resources .................................................................................................. 12 3.2 Financial Resources for Healthcare Delivery .............................................................................. 18 3.3 The Kenya Essential Package for Health (KEPH) System ............................................................. 23 3.4 Challenges in Healthcare Delivery System ................................................................................. 28 4.0 CONCLUSIONS ................................................................................................................................. 35 4.1 Organisation of the Healthcare Delivery System ........................................................................ 35 4.2 Reforms in the Health Sector ...................................................................................................... 35 4.3 Distribution of Health Facilities................................................................................................... 35 4.4 Human Resource ......................................................................................................................... 36 4.5 Health Financing ......................................................................................................................... 36 4.6 KEPH System ............................................................................................................................... 36 4.7 Challenges ................................................................................................................................... 37 5.0 RECOMMENDATIONS...................................................................................................................... 38 5.1 Prioritization of Service Delivery to the Poor and Level I ........................................................... 38 5.2 Improve Efficiency and Effectiveness ......................................................................................... 38 5.3 Rationalisation and Distribution of Facilities .............................................................................. 38 5.4 Rationalisation and Deployment of Human Resource ................................................................ 38 5.5 Capacity Utilisation ..................................................................................................................... 38 5.6 Consultation and Communication .............................................................................................. 38 5.7 Decentralisation and Role of Government ................................................................................. 38 5.8 Alternative Approaches to Healthcare Financing ....................................................................... 39 ANNEXES ............................................................................................................................................... 40 Annex 1: Persons Interviewed .......................................................................................................... 40 Annex 2: Terms of Reference ............................................................................................................ 42
Introduction The Government of Kenya controls the health sector through the Ministry of Medical Services and the Ministry of Public Health and Sanitation. The division of the ministries and their functions run through from the headquarters down to the field offices. These functions are currently the target of reform initiatives which have been going on in the health sector since the publication of the Health Sector Policy Framework in 1994. Also as part of the reforms, the introduction of the Kenya Essential Package for Health (KEPH) system has enhanced collaboration among the existing essential service packages and a shift from the previous focus on disease burden to the promotion of healthy lifestyles of individuals and communities. In this respect, the establishment of the six life-cycle cohorts and the classification of heath facilities into six levels of service delivery are important aspects of the KEPH system. The health sector is pluralistic where health services are provided by many players in the field including the public sector through the Government of Kenya (GOK) and parastatal organizations, the private sector comprising the Faith Based Organisations (FBOs) Non-Governmental Organisations (NGOs) and the Private for-profit facilities. The public sector is the largest provider and financier of health services and operates health care facilities throughout the country accounting for about 52% of all facilities. In the Vision 2030 Master Plan, several structural changes are envisaged to improve and expand the existing health sector in both public and private spheres to address the challenges. The government has therefore invited the private sector to join it in the delivery of health care services in line with the spirit of the Public Private Partnership. However as a major stakeholder in the sector, representing all private health sector players, the Kenya Healthcare Federation decided to carry out a baseline study to establish the status of healthcare delivery in both urban and rural areas. Study Approach and Methodology The overall objective of the study was to help KHF get accurate information that would help in designing an alternative healthcare delivery system, including mobilisation of financial resources which has remained a major challenge. It is expected that the alternative system would be sustainable, equitable, affordable and accessible to all Kenyans. The approach to this study was guided by the Terms of Reference provided by the Kenya Healthcare Federation. MICRODE Consult used participatory approaches of engaging key stakeholders and informants in the collection of the data and information from the facilities. The facilities covered by the study included representative samples of five provincial hospitals, five district hospitals, two Health Centres and at least one Faith Based Organisation/Non-Governmental Organisation and private hospital in each Province. Key Findings Physical and Human Resources The norms and standards for health service delivery have been set for four categories of infrastructure or physical resources: Buildings comprising medical and non-medical; Equipment ii
comprising medical and hospital equipment; Information and Communication Technologies (ICT): Radio call, telephones, networks; Transport services of various types. Kenya had a total of 5,299 health facilities from level I up to level VI comprising 337 hospitals, 768 health centres and 4,154 dispensaries. All these facilities are equipped with appropriate items to facilitate provision of services at the respective Levels. Different Levels have different staffing norms and standards. These constitute the minimum staffing levels for different staff cadres (e.g. medical specialist, medical officers, nursing officers and clinical officers) expected to be in place and provide the health services appropriate to the respective Levels. The study showed that there was overall staff shortage and although the minimum number could be in-post, this did not mean that it was the right quantity for the workload at the respective facilities. There was also sub-optimal distribution of staff with respect to type and geographical locations. Urban locations had favourable distribution compared to rural areas. Financial Resources Total Government Expenditure in the period 2005/06 was KShs 401,518,324,607 while Total Health Expenditure (THE) in the same period was KShs 70,807,957,722. With a population of approximately 37,000,000 then, THE per capita was KShs 1,987 (approximately US$ 27), and THE as a percent of total Government Expenditure was 5.2%, which is below the Abuja Declaration target of 15%. The World Health Organisation (WHO) Commission on Macro Economics recommends a per capita health spending of US$ 34 for financing essential package for health services. Kenya’s healthcare spending is therefore below the WHO recommendation by about US$ 7 per head. The challenge therefore remains how to bridge this resource gap, how to allocate the limited resources more efficiently and how to raise more domestic resources for investing in the health sector. It should be noted that in 2001/02, government spending on health was 8% of total government expenditure, 5.2% was therefore a reduction. In 2005/06, out of pocket (OOP) expenditure was the largest contributor to health care financing, followed by donors and the Government. 35.9% of Total Health Expenditure was met by households, while 29.3% was paid for by government. Private companies contributed 3.3% while donors contributed 31.0%. In terms of managing the funds, the Ministry of Health controlled the largest amount of the funds available for health care delivery. In 2005/06, Ministry of Health controlled KShs 25,050,931,100 (35%), which was essentially the Ministry of Health Budget allocation, followed by households (OOP) who controlled 20,611,667,607 (29.3%). In the third place were the NGOs controlling KShs 12,908,526,174 (18%). Private employer and insurance companies were a distant forth controlling KShs 3,849,460,713 (5%) followed by NHIF in the fifth place with KShs 2,632,570,016 (4%) of the funds. Ministry of Health allocation has consistently been skewed in favour of secondary and tertiary health facilities which absorb 70% of health care expenditure at the expense of primary care units which are the first line of contact with clients and also providing the bulk of health care services. KEPH System The National Health Sector Strategic Plan (NHSSP) II (2005 – 2010) introduced the Kenya Essential Package for Health (KEPH) to be used as a system of delivering healthcare services. The services are iii
KEPH has identified health needs of individuals through six stages of human life cycle (referred to as cohorts). With respect to resources. Challenges The challenges facing the healthcare service can be categorized into the three components of the KEPH system namely: Service delivery. the current practice whereby public facilities are required to only source their supplies from Kenya Medical Supplies Agency (KEMSA) has created a monopoly whose effectiveness and efficiency are lacking. The Government has already established norms and standards which are used in determining whether these challenges are being overcome or not. and Service delivery support systems. However. lack of maintenance systems to ensure serviceability and functionality of existing infrastructure. KEPH system brought about the shift in the approach to health care delivery from focusing on disease to promotion of healthy lifestyles. The rest of the staff had heard about KEPH but lacked details of its application. KEPH has also introduced a planning and management process that starts from the community level and works upwards to national level.to be delivered through six Levels of healthcare including the Community Level. and shortage of skilled personnel to use and maintain the infrastructure. The human resource has been negatively affected by staff shortage and sub-optimal distribution of available staff. It recognises that each cohort has unique health needs. infrastructure challenges range from shortage of some critical infrastructure. Service delivery resources/inputs. The first phase covering human life.
. At Level IV of public facilities. Large out of pocket expenditure which cannot be budgeted or programmed for. pregnancy. Even up to now. the levels of awareness of KEPH vary considerably across service levels and among staff. They however added that the idea had been sold to them. Regarding availability of commodities. the matrons and registered clinical officers were found to be well versed with KEPH. Financing healthcare has remained a challenge to the Government of Kenya for a long time. Other phases were to be incorporated in the subsequent AOPs up to AOP5 covering 2009-2010. inappropriate allocation of financial resources within the government health budget. The roll out of KEPH was phased. low public awareness on the need for health insurance. At Level III. the private sector health players have not been fully incorporated and therefore their contribution which was envisaged cannot be quantified. Key challenges in financing healthcare include. In the area of service delivery. Effective and efficient utilization of the systems to achieve the desired results as well as to achieve savings in the use of resources is also a challenge. KEMSA has adopted the “push” system and thereby forcing the facilities to receive medicines which they have no immediate use for. low investment in health by government. and delivery and new born up to two weeks was included in the first Annual Operational Plan 2005/2006. but resources were not made available for implementation. There have been challenges in the service delivery ever since the roll-out of the first package. it was established that the Medical Superintendents and the matrons in charge of maternity were aware of KEPH. support systems shortage or lack of qualified staff with management capacity and ability to motivate staff and offer leadership is a big problem.
With respect to the poor and indigent. With respect to Kenya’s annual healthcare spending. the government must maintain its social responsibility and roll-out specific health plans for them. The reforms currently underway are largely confined to the public health sector and yet the private health sector should be part and parcel of the reforms. distance to the nearest facilities as well as the number of ward beds and cots available per region. Key recommendations The KEPH system has recognised households and communities as the most important Level in reversing the downward trend of health indicators and therefore much more attention should be given to it in terms of resources. including urban-rural. Deployment and utilisation of service delivery support systems will bring about much more effectiveness in achieving results and efficiency in lowering operational unit costs. Information flow to enable the players in the health sector to be aware of the changes taking place is very important. The move towards universal health coverage should make it mandatory that all Kenyan residents enrol with at least one health plan. The role of the Central Government should be confined to policy formulation and regulation of the health sector. the challenges facing the healthcare service delivery and the health sector as a whole cannot just be addressed by merely pumping more money into the sector. It is important to rationalise the distribution of health facilities across the country in terms of population. There is need for intra-provincial and inter-provincial. Clearly established channels of communication are urgently required to address the information needs of all the stakeholders. The study also showed that the resources have not been equitably distributed. The recruitment and training of staff to acquire the right skills to enable them perform their duties is critical to enhancing capacity utilisation. staff redistribution to bring about a more equitable deployment of available staff. However. The bottlenecks affecting efficiency. It is necessary for the Government/Ministry of Health to fully decentralise and entrust healthcare delivery to semi-autonomous public and private sector health facilities. effectiveness and capacity utilisation must first be tackled for increased spending to bring about desired results.
.Conclusion The splitting of the former Ministry of Health into two ministries of Medical Services and that of Public Health and Sanitation has brought with it challenges of coordination which are crucial for the activities of healthcare delivery to be handled seamlessly. it is still below the WHO recommendation by about US$ 7 per head and the country needs to find appropriate strategies to raise its level of spending.
In the new arrangement. Non-Governmental Organisations (NGOs) and the Private for-profit facilities.1
Overview of the Health System in Kenya Organization of the Ministries in Charge of Health Services
Previously. It also oversees the two National/Referral hospitals both of which are semi-autonomous government agencies and teaching medical facilities. The public sector is the largest provider and financier of health services and operates health care facilities throughout the country accounting for about 52% of these facilities. the establishment of the six lifecycle cohorts and the classification of heath facilities into six levels of service delivery are important aspects of the KEPH system. the private sector comprising the Faith Based Organisations (FBOs).1. 1. the introduction of the Kenya Essential Package for Health (KEPH) system has enhanced collaboration among the existing essential service packages and a shift from the previous focus on disease burden to the promotion of healthy lifestyles of individuals and communities.1. Table 1: The public healthcare system comprises of the following levels of facilities: Level Facility Type VI Tertiary Hospitals V Secondary Hospitals IV Primary Hospitals III Health Centres. Clinics Interface I Community: Villages/Households/Individuals The health sector is pluralistic in nature. These documents form the foundation of the health sector reform programmes and have guided the implementation of the on-going reforms. However. The control of the two ministries is vested in two respective Ministers and their Permanent Secretaries. This division of the control and functions is replicated from the headquarters of the two Ministries and runs through up to the field level. District and Sub-District hospitals within the public sector and oversees their equivalents in the private sector. where health services are provided by many players including the public sector through the Government of Kenya (GOK) and parastatal organizations. 1
. Also as part of the reforms. Nursing Homes II Dispensaries. the Ministry of Medical Services is directly in charge of all medical facilities falling under the Provincial. The introduction of the Sector Wide Approach (SWAp) to health planning and funding has gone a long way in bringing together all the players in the sector within the spirit of Public Private Partnership. the provision of healthcare services in the country was the responsibility of the Ministry of Health. Maternities.0
1.1 1. namely.2 The Health Care System Kenya’s current health care systems are anchored on the Health Sector Policy Framework of 1994 and the subsequent National Health Sector Strategic Plans 1999-2004 and 2005-2010. The Ministry of Public Health and Sanitation is in charge of Health Centres and Dispensaries. the Ministry of Medical Services (MoMS) and the Ministry of Public Health and Sanitation (MoPHS). the formation of the Grand Coalition Government saw the Health Ministry split into two. In this respect.1.
maintain quality standards. attention is focused on the preventive and curative services. The facilities include hospitals. In the public sector. The public health service is complemented by for-profit and not-for-profit facilities owned by private entities.1.3 The Health Service Delivery The basis of the health care service delivery are the Annual Operational Plans (AOPs) which establish the interventions. now prepare their own annual plans to guide them in the health care service delivery. Aga Khan Hospitals in Mombasa and Kisumu fall in this level. They also offer ambulatory services to the communities. and activities to be undertaken in the course of the year. These comprise over 45% of health facilities in the country. The principle of bottom-up-approach to planning has given root to the decentralisation of health services to an extent that annual plans are no longer a preserve of headquarters. At the community level. The Community level comprising villages. (i) Organization of the Public Health Service Delivery The delivery of health care services in the public sector is vested in various facility management committees. health care interventions and services are guided by the respective AOPs prepared by the Village Health Committees and approved by the Community Health Committees. At the same time. It will be implemented by Community Health Extension Workers. households and individuals is the foundation of service delivery priorities in the new arrangements of the KEPH system of health care delivery. and clinics. District and sub-district or primary hospitals offer referrals and guidance to Health Centres. therapeutic and rehabilitative services. the equivalents are Aga Khan University Hospital and Nairobi Hospital. maternity homes. and control all district relevant activities. Dispensaries are meant to be the first line of contact with the community. they concentrate on their core functions required of their level. mostly adapted to the local needs. Facilities and various committees already established right from level I upwards.National referral and teaching or tertiary hospitals are at the apex of the health care system. 2
. With respect to Health Centres. They oversee the implementation of health services in the districts. these are represented by Kenyatta National Hospital in Nairobi and Moi Teaching and Referral Hospital in Eldoret. facility management boards and the medical staff employed in those facilities. They also offer basic curative services. The plan will generally highlight basic preventive and curative services and education materials. 1. The dispensaries provide a wide coverage of preventive health services which is critical in the achievement of the health sector reform focus on the individual life style and the community. NGOs. Community Health Workers and Community Own Resource Personnel. Provincial or Secondary hospitals offer referral to their respective district hospitals. faith-based organisations and individuals. In the private sector. The referrals offer sophisticated diagnostic. programmes. Village Health Committees are expected to be forums through which individuals and households can participate and contribute to their own health and that of the community. This feature is also shared by the health centres.
II. Integrated district annual plans comprise all activities captured in levels I. The Government and some donors however give some support to faith-based and nongovernmental institutions to undertake some specific programmes and services. They also consolidate the integrated district plans and the provincial facility plans into integrated provincial plans. Provincial and District Health Sector Management Boards have supervisory and quality control roles over all private sector facilities in their respective areas of jurisdiction. Furthermore the Government supports Immunisation services in all health facilities irrespective of their ownership. parastatals and semiautonomous health bodies are prepared by their respective planning units for implementation. and IV.1.259 Source: Ministry of Medical Services Facts and Figures 2008
.4 Healthcare Facilities The latest figures by the Ministry of Medical Services for overall healthcare facilities show that there has been substantial increase in these facilities in comparison to the figures which were released by the Ministry of Health in 2005. The national AOP is submitted to the Health sector Coordination Committee for approval. 1.122 617 1. They are structured in such a manner as to reflect the philosophy and principles of their owners. seconding personnel and providing some drugs. Provincial Health Management Teams and the Provincial Medical Services Management Teams prepare their respective plans for interventions and services.643 5. The plans will be approved by the respective Health Management Committees.778 838 1. AOPs will be prepared by the officers in charge and their respective staff. the health plans and services of the two ministries. non-governmental and the private for-profit institutions. The national Annual Operational Plan is therefore a consolidation of all provincial plans and the headquarter plans. The private sector facilities are expected to operate within the healthcare service delivery standards and protocols set by government and observed by all facilities including those in the public sector.154 Total 2. health centres by 77 and dispensaries by 640 more facilities: Table 2: Distribution of Health Facilities by Type and Controlling Agent Facility Type GOK FBO Private Total Hospitals 191 76 70 337 Health Centres 465 145 158 768 Dispensaries 2. District structures include the District Health Management Team and District Medical Services Management Team which prepare and implement their respective annual plans and services using their staff. For example the Government helps some faith-based hospitals by training their staff.At the dispensaries and health centres.415 4. The tables 1 and 2 below show that hospitals increased by 225. At the national level. Private for-profit facilities are run on profit basis and do not expect to be funded by the government in any manner. III. (ii) Organisation of Private Sector Facilities These facilities include faith-based.
1 Central 4.4 Total 37.871 12. The enrolled nurses at the dispensaries provide antenatal care and treatment for 4
.954 1.5 2004 Number of Beds/cots 5.006 196 3.1 Sources: GOK Publications. Ministry of Health.2 Coast 3.2 23.3 30.2 30.992 65.500 52. 2005
Table 4 below shows how hospital beds and cots were distributed per 100.542 8. Registered Community Health Nurses.183. HMIS 2005 1.0 Eastern 5.0 13.800 14.374 362 4.557 71 69 72 64 13 102 98 73 562 61 95 37 79 14 118 196 91 691 395 392 344 695 74 336 1.7 18.543 8. National average shows that 53. They form the first point of contact between the community and the formal government structure of health facilities.3 Rift Valley 9.3 16.1
Source: Health Management Information System.4 15.871 8.3 15.556.700 71.400 39.2 16.6 22.200 55.100 36.514 527 556 453 838 101 556 1.1.382 493 526 440 837 88 548 1.4 14.528 8. Table 4: Distribution of population.528 8.034.261 1.5 19.400 79.080 198 3. Dispensaries are staffed with Enrolled Community Nurses and Community Health Extension Workers.992 65.000 population by provinces in 2007.900 52.000 population was 18.267 358 4.4 19.832 6. The services provided by the staff at the primary facilities cover all cohorts and are commensurate to their capacity as determined by the standards and norms set by the two ministries in charge of the health services.3 16.954 12.0 18.4 21.802.1 21.3 North Eastern 1.402.900 56.313.1.0 15.000 population Nairobi Central Nyanza N/Eastern R/Valley Eastern Western Coast Total 58 65 64 65 8 98 100 68 526 54 89 42 80 12 117 161 94 649 381 372 334 692 68 333 1.2% of the population lived within 5 kilometres to the nearest facility.767 5.871 8. It also shows that national average for the number of beds and cots per 100.000 population 20.Table 3: Distribution of Health Facilities and Hospital Beds and Cots by Province
Number of health facilities in Kenya and number of hospital beds and cots by province SPA 2004 Number of Institutions 2003 Dispensaries Total Hospitals 2004 Hospital beds and cots 2003 Number Health centres Dispensaries Total Number of beds/cots per 100.6 26.8 20.402.443.261 1. MOMS Facts & Figures 2008.5 Primary Care Facilities at Levels II and III These facilities are comprised of Dispensaries and Health Centres.2 26.228. Laboratory technicians and Pharmaceutical technologists.4 18.851 21.951 6.000 population Nairobi 3.6 Western 4.1 13.9 31. Health centres have Registered Clinical Officers.287 12.971 Number per 100. beds/cots and nearest distance to facility by Province Province Population % population with less than # hospital beds and (2007) 5km to nearest facility coats per 100.1 Nyanza 5.3 18.
nurses.1. Obstetrics and Gynaecology. They refer difficult cases to district hospitals. Non clinical support services. ENT specialists. ophthalmologists. dentists.6 Level IV Facilities Most District hospitals are Level IV facilities and form primary facilities at the district level for clinical services. nose and throat. radiographers.1. Availability of the above skills has enabled the provincial hospitals to offer the services in the following disciplines: Medicine. They are the first referral hospital for both public and private primary facilities at Levels II and III. radiologist. Dental services. 1. 1. specialized and general nurses. paediatricians.simple medical problems during pregnancy and conduct normal deliveries. Their compliment of human resource include medical specialists such as physicians. obstetricians/gynaecologists. minor surgical services as well as outreach services. surgery including anaesthesia. They provide more specialized care with skills and competences not available at the district hospitals. pathologist. orthopaedic surgeon. surgical and outpatient activities. Accident and emergency services. anaesthetist. General surgery and anaesthesia. medicine. child health. They provide the following services: Curative and preventive care and promotion of healthy lifestyles.7 Level V Facilities All Provincial hospitals (and some district hospitals) are at Level V and form secondary level facilities. laboratory technologists and nutritionists. Their range of human resource includes: Medical officers. Twenty four hour service including ambulance and emergency services. Specialised services such as obstetrics and gynaenocology. Ophthalmology. Clinical and treatment techniques not available at lower levels. Laboratory and other diagnostics techniques to support medical. Health centres provide a wider range of services including basic curative and preventive services for all cohorts. They also provide outpatient curative care. Psychiatry. Ear. Referral services. clinical officers. and medical officers among other support skilled staff. Training and technical supervision to health centres and to act as resource centre. 5
. Paediatrics. Dermatology. dental technologists. pharmacists. psychiatrists. dermatologist. They are at the apex of field level medical facilities. In patient care. Intensive Care Unit (ICU) and High Dependency Unit (HDU). anaesthetists. surgeons.
Their research goes a long way in formulation of government policies. They have more concentration of resources and expensive to run. 1. nurses and medical officer interns. maternity. home care. Health care: The referral institutions are the ultimate facilities for offering complex curative health services for Kenyans and the neighbouring countries. The referrals can thus come from the district. The Ministry of Medical Services provides oversight. quality health protocols. Teaching and training for health care personnel e. They also provide preventive services and run several health programmes within the hospitals and as outreach for the communities. To this end. the two institutions are engaged in the teaching and training of manpower both at graduate and post graduate levels. Quality Health Protocols: It is expected that the teaching hospitals constitute the ideal institutions for setting standards in healthcare delivery because of their continuous activities in both academic and practical environments.1. The government categorises them at levels commensurate to each facility and in tandem with government facilities. supervisory and regulatory roles over them. 1. They have extra.1.8 Level VI Facilities Kenyatta National Hospital and Moi Teaching and Referral Hospital are the only two tertiary public facilities in the country at Level VI category. research. non-governmental organizations. They are teaching and training centres of excellence and provide more complex health care services requiring sophisticated technology and high skills. Faith-based and NGOs are generally not-for-profit institutions. private foundations and companies. home hospitalisation and outreach. apart from their routine activities.9 Private Sector Facilities The health facilities outside the government structure include hospitals. publication and dissemination of research findings. nursing homes and clinics. The two institutions operate as semi-autonomous government agencies and offer health care services. The referral hospitals. They teach and train health workers at pre-service and in-service levels. This should result in high clinical standards and innovative treatment protocols Research: One of the core functions of a university is research. They provide mostly curative services and are operated by faith-based organizations. are involved in cutting edge research to find solutions to myriad health problems which still defy medical knowledge to this day.mural treatment alternatives to hospitalisation such as day surgery. 6
. Technical support to district hospitals. Supervision and monitoring of district hospitals. provincial or other private sector facilities or from the health facilities in the neighbouring countries. Teaching and Training: The major reason for the establishment of the referral and teaching hospitals is to teach and train critical high skilled manpower required for the provision of health services in the country.They also offer the following support services: Laboratory and diagnostic.g. teaching and training.
and is the apex organisation for private healthcare providers in Kenya. Their management may be by government. FBOs or private enterprises. the healthcare delivery is currently faced with many challenges and various reforms are currently being implemented or proposed for implementation.11 Health Sector Priorities Preparation of NHSSP II and the introduction of the KEPH system were done within the overall broader picture of Economic Recovery Strategy 2003-2007 of the NARC government. several structural changes are envisaged to improve and expand the existing health sector in both public and private spheres to address the challenges.1. Key components of the ERS policy as it relates to health sector included: Introduction of National Social Health Insurance Fund. KHF pro-actively and constructively engages with the government and other stakeholders to deliver accessible. However.2 Rationale for the Baseline Survey The Kenya Healthcare Federation (KHF) is a member of the Kenya Private Sector Alliance (KEPSA). Under the Vision 2030 Master Plan. The government has invited the private sector to join it in the delivery of health care services under the Public Private Partnership.10 Voluntary Counselling and Testing Facilities HIV and AIDS voluntary counselling and testing (VCT) services are provided by several VCT centres which have been set up county-wide.000 53% 7. affordable and quality healthcare through enabling policies that maximise the contribution of private sector. 7
. Increasing government funding to the health sector. 1. Increasing efficiency and effectiveness through Sector-Wide Approach to planning and funding.2% 11% 12% 74% 38%
Target 2008 110 560 45% 12% 15% 16% 85% 45%
1. MOMS Fact & Figures
Baseline 2003 115/1000 590/100.1. Focusing on health investments to benefit the poor. However as a major stakeholder in the sector.1. NGOs. KHF decided to carry out a baseline study to establish the status of healthcare delivery in both urban and rural areas. It was envisaged that fulfilling the above priorities would assist in achieving the following selected targets: Table 5: ERS Targets for the health sector Indicator Development Outcomes Reduce under 5 mortality rate Reduce maternal mortality Reduce HHOOP expenditure Outputs Increase GOK expenditure to health Increase health budget allocation to health centres and dispensaries Increase health budget allocation to drugs Increase proportion of fully immunized children Increase contraceptive prevalence rate Source: NHSSP II. Increasing cross-sector cooperation between health sector and other socio-economic sectors.
comment.1. affordable and accessible to all Kenyans.1 Objectives of the Assignment The overall objective of the assignment was to help KHF get accurate information that would help in designing an alternative healthcare delivery system. including mobilisation of financial resources which has remained a major challenge. critique and make proposals on the baseline package of health intended to be delivered and known as KEPH (Kenya Essential Package of Health). Identify alternative ways of improving healthcare delivery through Public Private Partnership. equitable.
. Identify gaps and challenges in the provision of healthcare. Study. Specific objectives of the study are to: Establish the type and distribution of existing physical resources available for healthcare.2. It is expected that the alternative system would be sustainable. Establish magnitude and sources of funds available for healthcare services.
Both purposive and random sampling methods were applied.2. However. This was necessary to ensure that there was a representation of districts within and without the capital/provincial headquarters.based and private facilities located around the provincial/district headquarters. Table 6: Geographical Coverage Sample Region Location Coast Mombasa and environs Lake Kisumu and Environs Highlands Embu and Environs Arid/Semi Arid Machakos and Environs Rift Valley Nakuru and Environs Capital City Nairobi 2.1 Sampling Strategy and Sample Design A multi stage sampling technique was used to select facilities for inclusion into the study. two Health Centres and at least one Faith Based Organisation/Non-Governmental Organisation and private hospital in each Province. The same procedure was used in picking the faith. five district hospitals. The facilities covered by the study included representative samples of five provincial hospitals. Rift Valley. 2.2.2 Purposive Sampling The study covered different geographical areas with a view to capture different attributes of the climate and population of Kenya and their effect on health. Arid and Semi Arid and the Capital City. 2.0 STUDY APPROACH AND METHODOLOGY
2. Random sampling was applied in picking the health centres which are scattered in a radius of 20 kilometres around the district headquarters. This could be changed to include exceptional cases.2. Highlands. Lake. it was decided that it was safe to consider old districts where clarity was lacking. below.2.1 Approach The approach to this study was guided by the Terms of Reference provided by the Kenya Healthcare Federation. The areas include Coastal. These are presented in Table 6. The tools included open ended and semistructured questions that would allow focused. two-way conversational communication between the consultant and the key respondents.2 Methodology 2. MICRODE Consult used participatory approaches of engaging key stakeholders and informants in the collection of the data and information from the facilities.
. because there is still some confusion with respect to the new districts in several areas.3 Random Sampling A mixture of purposive and random sampling was applied in picking the district facilities. Open ended questions were designed to allow flexibility for probe and detailed discussion.
Kisumu Shalom Hospital. Six facilities were to be visited in each of the five provinces. SWAp initiative.1 Survey Tools (a) Questionnaires These were developed to collect information covering the following areas: Resources for Healthcare delivery: The resources enquired included human. Key Informant Interviews and Focus Group Discussions guides. Family Planning services.5. Mombasa Centre -Diani Rift -Rongai Molo Rift Valley Mercy Mission Valley -Njoro Hospital. Mombasa Valley Hospital. All were fully qualified diploma and above in reproductive health and currently working in public facilities. health centres. This was followed by one day training on the questionnaires and field testing of the same. pricing and overall satisfaction. faith-based/NGO and private facilities. Machakos Nairobi -Langata Mbagathi Kenyatta St. The instruments developed were a mixture of Questionnaires. Table 7: Health Facilities Sampled for the Healthcare Delivery Survey Province Health District National/Prov.2. Maternal child healthcare services: The services enquired included antenatal and postnatal care.5 Development of Instruments. 2. Training and Pre-Testing The survey instruments were developed by the consultants guided by the objectives of the study and were shared with the representatives of Kenya Healthcare Federation.2.2. Nairobi Coast -Tiwi Rural Msambweni Coast Mewa Medical Training Centre. (b) Focus Group Discussions The tools for focus group discussion were developed to guide discussion on the KEPH system. Nakuru 5
. Recruitment took place at each provincial headquarters. The distribution and numbers of facilities sampled are indicated in the table below.2. Health Financing and Public Private Partnership. Mary’s Mission -Mathare Hospital. Faith Based Centre Hospital Hospital Nyanza -Rabuor Kisumu New Nyanza St. district hospitals. physical and infrastructure.2 Training and Pre-testing A total of ten research assistants were used in the survey. Kisumu Eastern -Kaviani Machakos Embu Bishop Kioko -Mitabooni Catholic Hospital. Monica’s -Nyahera East Hospital. These included national/provincial referral.4 Survey Design A total of 30 facilities were visited during the survey. 2.2. vaccine logistic system and child healthcare services. Machakos Nairobi West Hospital Pandya Memorial Hospital. Koibatek Total 10 5 5 5 2. 10
Private Owned Jalaram Hospital.5. Client Satisfaction Survey: to assess service utilization.
A total of 30 facilities as indicated in 2.2. focus group discussions and key informant interviews in all the facilities which were visited. received services and were now leaving the facility. 2. Entry and Analysis 2. They also administered client satisfaction tools on the patients who had been attended to at the facility. The consultants conducted focus group discussions.
.2.6. the consultants and the respective team of research assistants worked together at the same facility to ensure quality control. The data was entered into the computer for processing using SSPS software and EXCEL.2.4 above were visited. This also included strict supervision of the research assistants. To ensure uniform standard and quality control. The output was checked and cleaned to facilitate cross tabulation and subsequent analysis and presentation of graphs and tables.2 Data Entry and Analysis All the data from the field was transported to the offices of MICRODE CONSULT in Nairobi. the survey started in Nairobi where all the consultants worked and conducted all activities together. Research assistants administered the tools on heads of service areas.1 Data Collection The baseline survey used a mixture of questionnaires.2. key informant interviews with facility management staff in charge of various units and functional areas.6.6 Data Collection. Any anomalies detected would be rectified the following day.2. This analysis formed the foundation of findings and draft report writing. Each consultant checked all the questionnaires at the end of each day to ensure completeness and correctness of the exercise. In all the facilities visited.
Radiology unit. Administration unit. waiting area protected from sun and rain. The norms and standards for health service delivery identify four categories of infrastructure or physical resources: Buildings: medical and non-medical. Transport services of various types. MCP/FP services provision unit. appropriate infrastructure is required to ensure that the skills available have the right tools and equipment to do their duties. Level V service provision units would require a minimum of 10 acres and would contain all areas listed under level IV plus: Intensive care unit.299 health facilities from Level II up to Level VI comprising 337 hospitals. and seasonal or shortage of water.1
Physical and Human Resources Physical Resources
NHSSP II and the KEPH system recognize that for efficient utilization of human resources. 768 health centres and 4. Medical engineering. Pit latrine.1 3. Staff housing. Staff housing. Norms and standards have been set for different levels as indicated below: Level III service provision units would require a minimum of 2 acres and would contain: Medical services provision unit with maternity and inpatient facilities. the facilities were checked to see if they had basic items such as client latrines. Pit latrine. Supplies services unit. telephones. basic level of cleanliness.0
BASELINE SURVEY FINDINGS
3. Supplies services unit. Level IV service provision units would require a minimum of 5 acres and would contain: Outpatient service provision unit. Equipment: medical and hospital equipment. Kenya had a total of 188.8.131.52 dispensaries. regular water supply. Table 7 below summaries what the survey revealed:
. (i) Buildings As already indicated in table 1. During the survey. Inpatient service provision unit. Information and Communication Technologies (ICT): Radio call. networks.
This could be done by facility staff or contracted outside support. In this regard. While acquisition of these items may be a one time purchase.1 (i) above are equipped with appropriate items to facilitate provision of services.1.Table 8: Service and Facility Infrastructure Facility Percentage of facilities with: Service comfort Regular Amenities such as supply Latrine. All facilities had regular water supply. their operations and maintenance pose very challenging obligation on the part of facilities administrations. (ii) Equipment In terms of norms and standards. The survey sought to find out how the authorities were handling these items. When a facility has a programme for routine maintenance it means that the equipment or building is checked regularly even if there is no problem. Basic cleanliness Provincial hospital 100 100 District hospital 100 100 Health centre 30 100 Faith based 100 100 Private 100 100 Total Source: This survey
water Seasonal shortage or lack of water
20 40 50 80 20
From the table. major equipment such as generator. three specific questions were asked to find out if the facility had a programme for routine maintenance and repair of building or infrastructure. However 20% of provincial. and small equipment such as blood pressure cuffs or stethoscopes. 40% of districts and health centres and 20% of private facilities had seasonal shortage or lack of water. all the provincial. The health centres achieved 30%. waiting area. private and faith based health facilities achieved basic service comfort amenities. Table 9: Equipment building maintenance Facility Number Percentage of facilities with: sampled Preventive System for Programme repair or for replacement Major of small equipment equipment Provincial hospital 5 100 100 District hospital 5 100 100 Health centre 10 30 100 Faith based 5 60 100 Private 5 100 100 Total 10
System for maintenance and repair of buildings 100 100 50 80 100
. All units itemised under 3. refrigerator and sterilisation. district. Table 8 below shows how the facilities responded. all major and small medical and non-medical equipment have been identified for specific levels of health care facility. Additionally level V should have a medical engineering unit to maintain the equipment.
facilities sampled were probed to ascertain their status with respect to availability of ambulance/vehicle for emergency transportation for clients. health facilities have been redesignated. districts and private facilities had preventive programmes for major equipment while only 30% and 60% of health centres and faith based respectively had the programmes. With respect to maintenance and repair of buildings. Five Level V facilities were visited during the baseline survey. Consequently. nursing officers and clinical officers) expected to be in place. level IV and V to have communication equipment. medical officers. which are the minimum staffing levels for different staff cadres (e. vehicles and motor cycle. Information and Communication Technology Transport and communication form components for the KEPH system.According to the above. medical specialist. the terms Levels V. district and private facilities had established the systems. The norms and standards require level III to have communication equipment. Coast and New Nyanza Provincial General Hospitals. IV and III respectively are applied. only 50% and 80% of health centres and faith based respectively had systems in place while all provincial. All facilities had system for repair or replacement of small equipment. during the survey. namely. only 30% of health centres reported having transport while only 80% and 70% had functional computer and telephone respectively. Table 10: Transport and ICT Services Facility Number Percentage of facilities with: sampled Ambulance/vehicle Functional For emergency computer
Provincial 5 hospital District 5 hospital Health 10 centre Faith 5 based Private 5 Total 30 Source: This Survey
100 100 30 80 100
100 100 80 100 100
Working telephone during service delivery 100 100 70 100 100
These are basic facilities and it was hoped that all facilities should be fully equipped with them. They support facility needs for mobility.g. Machakos District Hospital was also indicated to be a level V health facility and has therefore been categorised so in this report. Rift Valley.2 Human Resources
In line with KEPH system approach to health service delivery. functional computer and a working telephone. Different Levels have different staffing norms/standards. Instead of being referred to as Provincial General Hospitals. 3. all provincial. District Hospitals or Health Centres. Eastern. However as can be seen. (iii) Transport.1. telecommunications and internet to enhance efficiency and effectiveness in client service delivery. 14
physicians. This means 25 pharmacists could have been redeployed in lower level facilities. Table 11: Staffing vis-a-vis Staffing Norms in Level V Facilities Visited
Public Level V Facilities Coast P. Negative numbers denote the number of personnel above the norm/standard requirement. Medical Specialists that needed to be posted according to the norms were 120. were actually on the ground. 6 Pharmacist Technologists. Health service delivery could be improved by better staff distribution among facilities of different levels of health service. increases as one moves downward the ladder from Level VI to Level III facilities. while 35 were actually on the ground. The survey revealed two things. therefore a shortage of 20 pharmaceutical technologists. Level IV facilities visited surpassed the norm by a total of 36 while the 10 Health Centres visited had a total shortage of 52 nursing officers.G.H.G. On the other hand. H. 220 Nursing Officers. surgeons or dermatologists. Severity of staff shortage. In the Level V facilities (as named above) visited. This means that 24 could have been deployed elsewhere in the country where the staffing norms were not met. 16 Clinical Officers.(i) Provincial General Hospitals / Level V Health Facilities Level V facilities are expected to have 24 Medical Specialists with different specialisations: e. According to the norms. while actually on the ground there were 91. and 7 Laboratory Technicians. This is sub-optimal distribution of personnel.G. that this minimum staffing level was mostly not met and that there are cases where one facility had more than the minimum recommended number and yet another facility had less than the recommended minimum number of that cadre. a total of 10 pharmacists were required in the five facilities according to the norms. There was a shortage of 9 laboratory technicians as the norm required that the five facilities should have a total of 35 laboratory technicians while on the ground only 26 laboratory technicians were in place. 15 Medical Officers. H. 4 Anaesthetists.H Rift Valley P. leaving a shortfall of 71. Medical Officers required according to the KEPH norms were 75.g. especially for nursing officers. Embu P. there should have been a total of 30 pharmaceutical technologists but there were only 10 on the ground. Total Medical Specialist Norm Actual 24 10 24 10 24 15 24 6 24 8 120 49 Rqd 14 14 9 18 16 71 Medical Officer Norm Actual 15 21 15 11 15 27 15 13 15 19 75 91 Rqd -6 4 -12 2 -4 -16 Clinical Officer Norm Actual 16 25 16 56 16 27 16 25 16 22 80 155 Rqd -9 -40 -11 -9 -6 -75 Nursing Staff Norm Actual 220 349 220 401 220 171 220 231 220 261 1100 1413 Rqd -129 -181 49 -11 -41 -313
. 2 Pharmacists. only 49. Obstetrics and gynaecologists. The above information is summarised in the table below.G. Machakos D. that is less than half. Hospital New Nyanza P. Pharmacists were generally found to be adequate at Level V facilities. The Level V facilities visited surpassed staffing norm for nursing staff by a total of 313.
The actual number on the ground was 14. which means they had excess of two according to the norms. New Nyanza P. Instead of the four facilities visited having a total of 8 pharmaceutical technicians.H. every Level IV facility should have 6 Medical Officers.G. and another had while one had no nutritionist at all. According to the norms/standards. that is.
Public Level V Facilities Coast P.H Machakos D.G. Rift Valley P.G.H. 16
. Of the four facilities visited. but they had a total of 23 pharmacists among them.Table 11 cont’d. which should have had 204 nursing officers but had 240. these four facilities should have had a total of 24 Medical Officers. Each Level IV facility is recommended to have 3 Laboratory Technologists. The excess of 36 is brought about by Mbagathi Level IV facility which had 124 nursing officers as compared to 68 nursing officers recommended for Level iv.G. hence the four facilities should have had 8 pharmacists. they had 11 who were sub-optimally distributed.. There was therefore a total shortfall of seven anaesthetists among the four facilities. Only one facility had an anaesthetist and only one. According to the norms/standards. they only had two. Only 18 Medical Officers were in place however. the four facilities visited should therefore have had 12 laboratory technologists. Each Level IV facility should have at least 2 pharmaceutical technicians. leaving six vacant positions for pharmaceutical technicians. There were 71 Clinical Officers in the four facilities compared to the recommended 28 (7 per Level Four facility). only two had 1 pharmaceutical technician each. The information above is summarised in the tables below.H Total Anaesthetist Norm Actual 4 2 4 1 4 1 4 4 20 1 1 6 Rqd 2 3 3 3 3 14 Pharmacist Norm Actual 2 6 2 11 2 6 2 2 10 5 10 38 Rqd -4 -9 -4 -3 -8 -28 Pharmaceutical Tech Norm Actual Rqd 6 3 3 6 4 2 6 0 6 6 6 30 1 2 10 5 4 20 Laboratory Technician Norm Actual Rqd 7 4 3 7 3 4 7 3 4 7 7 35 10 6 26 -3 1 9
(ii) District Hospitals / Level IV Facilities Four Level IV public health facilities were visited. The four Level IV facilities visited should have had a total of 8 anaesthetists according to the norms/standards. one rural facility had a shortfall of 12 nursing officers and the other a shortfall of 8 nursing officers. leaving a gap of 6 Medical Officers. The four facilities visited should have had a total of 4 nutritionists. This means 15 pharmacists could have been distributed to other facilities deficient of pharmacists.. each Level IV facility should have 2 pharmacists. Each Level IV facility should have at least two anaesthetists. It is also recommended that each Level IV facility should have one nutritionist. a case was found where one facility had 8 nutritionists. Data for Nursing Staff were only available for three facilities. Of the three facilities. This means there were 43 Clinical Officers who could have been deployed to other deficient Level IV facilities or to lower level facilities. Hospital Embu P. not the recommended two.
According to the norms/standards. being a provincial rural health training centre. Nor = Normal On the whole. Kisumu East D.while some met the staffing thresh hold.H...Table 12: Staffing vis-a-vis Staffing Norms in Level IV Facilities Visited
Public Level IV Facility Molo D. pharmaceutical technologists and laboratory technicians where the minimum norms were not met except for laboratory technician in Rongai. had extra functions which made its requirement more than the norms established for ordinary health centres.000 is 2 clinical officers. Msambweni D. Rqd = Required. staff deployment or distribution appears haphazard and does not adhere to the norms or standards as set out in the KEPH document. Pharmacist Nor Act 2 2 2 2 8 3 2 15 3 23 Rqd -1 0 -13 -1 -15 Pharm Tech Nor Act 2 2 2 2 8 0 0 1 1 2 Rqd 2 2 1 1 6 Laboratory Tech Nor Act Rqd 3 3 3 3 12 4 1 8 1 14 -1 2 -5 2 -2 Nutritionist Nor Act 1 1 1 1 4 1 0 8 2 11 Rqd 0 1 -7 -1 -7
Act = Actual. Langata and Mathare North health centres in Nairobi were endowed with human resources beyond the norms in the two categories sampled of clinical officers and nursing staff while meeting the norms for pharmaceutical technologists and laboratory technicians. Rongai.H. However. This also goes for nursing staff. Nor = Normal Table 11: Cont’d. On the other hand. D.
. 1 Community Oral Health Officer. Mitaaboni and Kaviani health centres which are farthest from the major towns had less than 2 clinical officers which is the minimum number required for a health centre. there were shortfalls in others. 14 nursing staff. Total Medical Officer Nor Act Rqd 6 2 4 0 6 5 1 6 6 0 6 5 1 24 18 6 Clinical Officer Norm Act Rqd 7 11 -4 0 7 7 0 7 35 -28 7 18 -11 28 71 -43 Nursing Officers Norm Act Rqd 68 56 12 0 0 68 60 8 68 0 0 68 124 -56 204 240 -36 Anaesthetists Norm Act Rqd 2 0 2 0 2 0 2 2 1 1 2 0 2 8 1 7
Act = Actual. Rqd = Required. D.
Public Level Four Facility Molo Hospital Msambweni Hospital Mbagathi Hospital Kisumu East Hospital Total D. the minimum number for key health staff required to deliver minimum package for a health centre serving a catchment area of 30. (iii) Health Centres/Level III Facilities Ten Level III facilities were visited.H. It shows that urban areas are favoured and have better staffing than the rural areas.H. 1 laboratory technician and 1 pharmaceutical technologist. Mbagathi D. Tiwi health centre in the Coast province. D. There were mixed results with regards to staffing levels in the ten level III facilities visited. Njoro and Diani health centres represent busy rural commercial centres where the norms have been met except for the nursing staff where the actual number of nursing staff was 9 against the norm of 14 in both cases.
01 8.072 15. MOPHS
Adapted from.29 6.2004/051 2000/01 2001/02 2002/03 2003/04 2004/05 Total 12.10 MoH Exp as % of TGE 7. It appears that health has consistently been under financed by the public sector. Nursing Staff Nor Act 14 9 14 8 14 9 14 16 14 17 14 3 14 4 14 4 14 4 126 74 14 15 Rqd 5 6 5 -2 -3 11 10 10 10 52 -1 Pharmaceutical Technologist Nor Act 1 1 1 0 1 1 1 0 1 0 1 0 1 0 1 1 1 0 9 3 1 1 Rqd 0 1 0 1 1 1 1 0 1 6 0 Lab Technician Nor Act 1 1 1 1 1 1 1 0 1 0 1 0 1 0 1 2 1 0 9 5 1 0 Rqd 0 0 0 1 1 1 1 -1 1 4 1
Overall staffing in the four categories shows that a redistribution of staff would ensure that norms are achieved in all the categories.351 11.05) in 2000/01. taxation. a policy framework for financing health care was developed in 1994. the cost of service delivery and the ability of the population to pay for it whether as insurance premium or as user fees. GoK . The methods for financial resources mobilisation should particularly pay attention to the socio-economic status of the population it intends to serve.234 15. There are two sides to service provision.97 506. to KShs 488.05 712.987 (US$ 27) the highest.44 in 2001/02 to KShs 1.05 6. Nor =Normal. Rqd = Required.44 1. user fees.52 9.49 488.51 1. 3.49 1.99 7. In Kenya.65 1. donors and health insurance.44 481.91 Source: Kenya National Health Accounts 2009.Household Health Expenditure Survey Report
.67 MoH Exp as % of GDP 1.441 23. Per capita health expenditure ranged from as low as KShs 395.67 Per capita US$ 5.49 (US$ 5.611 Expenditure Per capita KShs 395.28 6.23 9. MOMS.2 Financial Resources for Healthcare Delivery
Sustainable provision of health care requires a carefully thought out method for financial resources mobilisation. This policy framework identified several methods through which the required financial resources could be mobilised and these included. in 2005/6. Total Government Expenditure has always been below 2% of the GDP as shown in table 13 below: Table 14: Ministry of Health Expenditures 2001/05 .The above information is summarised in the table below: Table 13: Staffing vis-a-vis Staffing Norms in Level III Facilities Visited
Health Centre Clinical Officer Nor Act Rqd Njoro 2 2 0 Rongai 2 1 1 Diani 2 2 0 Mathare North 2 4 -2 Langata 2 4 -2 Mitabooni 2 1 1 Kaviani 2 1 1 Nyahera 2 6 -4 Rabuor 2 2 0 Total 18 23 -5 Tiwi 2 7 -5 Source: This survey Act = Actual.33 6.
Private Companies d.987 (approximately US$ 27). Public b.2 Sources of Funds for the Health Sector
In 2005/06. government spending on health was 8% of total government expenditure. while 29. Key a. Households c. followed by donors and the Government.0% 0.000. It should be noted that in 2001/02. THE per capita was therefore KShs 1. how to allocate the limited resources more efficiently and how to raise more domestic resources for investing in the health sector.2. 5. faith-based and NGOs).000 then.6072 while Total Health Expenditure (THE) in the same period was KShs 70.3% 35. Financing of Total Health Expenditure in 2005/06 is summarised below: Public (Government) Households Private Companies Donors Local Foundations Other (Not specified) 29.957. health service is financed mainly from the facility revenues user fees. 35. Private companies contributed 3. Kenya’s healthcare spending is therefore below the WHO recommendation by about US$ 7 per head.3% was paid for by the Government.In non-public facilities (private. (OOP).2%.3% 31. private companies and local foundations) therefore financed 39. 3.7223.9% of the total health expenditure.1% 0.807. With a population of approximately 37. Donors
Kenya National Health Accounts 2005/06 Kenya National Health Accounts 2005/06 4 The African heads of state and government committed to allocate 15% of government expenditure on health. while in public facilities it is financed mainly by MoH.9% 3. and insurance reimbursements.000) The private sector (households.
.1 Health Expenditure
Total Government Expenditure in the period 2005/06 was KShs 401.0%
Figure 1: Contribution as a % of THE (KShs ‘000.324. The challenge therefore remains how to bridge this resource gap.2% was therefore a reduction.3% of health care financing.4% 100. out of pocket (OOP) expenditure was the largest contributor to health care financing. and THE as a percent of total government expenditure was 5.9% of Total Health Expenditure was met by households.2. which is below the Abuja Declaration target4 of 15%. 3. OOP and insurance (NHIF) reimbursements. The World Health Organisation (WHO) Commission on Macro Economics recommends a per capita health spending of US$ 34 for financing essential package for health services.518.
When they receive the financial resources. Over the same period.050. public health centres and dispensaries 3.607 (29.931. 8.2. The financing agents include Ministry of Health.3 0.667.9%.9%.908.3%).9 31.638.4 0.232 25. the highest increase in contribution of 134% between 2001/02 and 2005/06 was made by donors followed by private. In 2005/06.957.541 % 29.990.343. Local Foundations f.807. The increase of donor funding decreased household share of contribution from 51. private and donors.7
57. Ministry of Health controls the largest amount of the funds available for health care delivery.646. Other (Not Specified) Table 15: Trend in Contribution by Financing Source Public Private Local Foundations Households Donor Not Specific 2001/02 16.522 % 29.878.761 29. 3.097.e.929.0 0.4 100.849.526.970 100.463.0 82. pharmacies and chemist shops 4. Other consumers of OOP are faith-based hospitals who consume 11.553.106 300. 82. which was essentially the Ministry of Health Budget allocation.7 679.721 Source: Kenya National Health Accounts 2009. Other Ministries.368 64. MOPHS
Table 15 shows that of the three major contributors namely government.174 (18%).713 (5%) followed by NHIF in the fifth place with KShs 2.100 (35%).1 16. in what proportions and where the funds are to be allocated.611. Understandably.570 359.632.6 2.1 (89. In the third place were the NGOs controlling KShs 12.224.893.2. The donor funding was mainly from Global Funds for Aids.570. MOMS.151.9) 134.1% to 35. in other words control how such financial resources are utilised.3%.3 0.016 (4%) of the funds. faithbased health centres and dispensaries 3.921 38.6%.6 51.287.180. Parastatals.954 9.3 Consumers of Out of Pocket Expenditure Private for-profit agents are the largest consumers of OOP expenditure (38%) followed by the government at 30%.3%.132 21.342 2.361. Private Insurance Companies and households.402. private clinics. and the Presidents Emergency Plan for Aids Relief (PEPFAR) 3.2%. 23%. Ministry of Health allocation has consistently been skewed in favour of secondary and tertiary health facilities which absorb 70% of health care expenditure at the expense of primary care units which are the first line
.202. TB and Malaria.1 2005/06 20.606.1% and lastly by government. Private employer insurance companies were a distant forth controlling KShs 3. followed by households (OOP) who controlled 20. they make decisions.9) (12.460.3 3. they decide how.343.0 70.1 35.767. the government contribution remained more or less the same at 29.0 %Change 23.887.624.242 1. Ministry of Health controlled KShs 25.1%.4 Management of Health Funds
Financing agents are those institutions that receive financial resources from whatever source for healthcare service delivery.
667.849.2 1. controlled about 57% of the financial resources in 2005/06 while the public sector controlled 43%.807.785.632.174 1.
.729.1 18.713 20. In 2005/06.526.957. MOPHS Figure 2: Agents Controlling Health Funds
The private sector.482.722 % 35.4 29.611. Table 16: Agents Managing Health Funds
Financing Agent Ministry of Health Office of the President Local Authorities National Hospital Insurance Fund Parastatals Private Employer Insurance OOP NGOs Private Firms Rest of the World Total Health Expenditure Funds (KShs) 25.4 1.6
Source: Kenya National Health Accounts 2009. NHIF and Private Health Insurance.3 5.693 70.7 1.6 3.221.100 1. Insurance health spending is divided into two.of contact with clients and also providing the bulk of health care services.050. (59.216.931.082 2.570.517 1.6%) was attributed to NHIF while the remaining KShs 3.849.607 12.908. MOMS. including the households and NGOs.570.676.9 2.016 936.378.713. total health insurance spending amounted to KShs 6.073 408.4%) was from private health insurance companies.016 ( 40.747 3.634.460.of KShs 2. Other agents managing health funds were Office of the President (2%) and parastatal agencies.7 0.484.460.632.814.030.
661. MOMS.149.777.018.349.597 0.537.3 Public health centres and dispensaries 6.0 Private clinics 4.302.227 35.033 13.932.2 Health administration 7.750.8 Private for profit hospitals 9.4 Total 70.594.327 8.824.373 1.191.722 Source: Kenya National Health Accounts 2009.019.9 Other 254.829.456 6.195 5.180 0.771 0. MOPHS
.592.223.6 Traditional healers 93.7 Provider of health programmes 10.957.844 15.0 Private pharmacies 1.719.6 Not for profit hospitals 3.476.Table 17: Breakdown of Funds by Provider 200/06 Provider 2005/06 % Public hospitals 25.918.922 2.807.1 Community health workers 497.797 10.346.5 NFP health centres & dispensaries 704.
The special health needs are immunization. messages on HIV/AIDS. 2 weeks to 5 years old. deworming. vitamin A supplementation and protecting the child or keeping the child away from danger. care for the new born and the mother. These levels have been identified as follows: Level I: Community level – the community to be empowered with information and skills . the life-cycle cohorts have unique health needs and services as identified here-below: Stage 1: Pregnacy.3. Stage 6: Elderly 60+. One of the key innovations of KEPH is the recognition and the introduction of level I services which are aimed at empowering Kenyan households and communities to take charge of improving their own health. Stage 3: Late chilhood. This cohort needs to be prepared for adolescence therefore health education. Stage 4: Adolescence. These are addressed through different relevant health messages. Level II & III: Dispensaries. They are faced with health problems such as diabetes. KEPH also introduced six levels where the healthcare services will be delivered. STIs. KEPH brought about the shift in the approach to health care. STIs. It further aims to integrate all health programmes into a single package that focuses its interventions towards improvement of health at each of the six different phases (stages) of the human development cycle. HIV/AIDS. The issues to be addressed at this stage include family life issues. KEPH recognises that in each of the six phases. The unique health needs are health education on drug abuse.3
3. Level IV – VI: Primary.1
The Kenya Essential Package for Health (KEPH) System Overview of KEPH
The National Health Sector Strategic Plan (NHSSP) II (2005 – 2010) introduced the Kenya Essential Package for Health (KEPH) system. Stage 2: Early childhood. The special needs at this stage are identified as antenatal and postnatal care. work and unemployment related issues. This stage calls for youth friendly services where the health service providers appreciate youth and are not judgemental about them. HIV/AIDs and drug abuse among others. Health Centres and Nursing/Maternity Homes – to provide mainly promotive and preventive health care with some curative health care. This is the age burdened by HIV/AIDS orphans. personal hygiene. but to know and progressively realise their rights to equitable and good quality health 23
. clinics. 13 – 24 years old. secondary and tertiary hospitals – to provide mainly curative and rehabilitative health care. hypertension and cancers. delivery and new born up to two weeks. in other words they are the carers. premature pregnancy.3. Stage 5: Adulthood 25 – 59 years old. 6 to 12 years old. It envisages building the capacities of households not only to demand services from the providers. from focusing on disease and curative to preventive and promotion of healthy lifestyles.
It also shows the overs and under-supply of delivery units across the provinces.187. Communication systems/ICT.358
5. From the table. Monitoring and evaluation.563. health facilities have been repurposed into service delivery units and reclassiified into Levels.2 Gap Analysis of Service Delivery Units As already indicated.801. Maintenance. Performance monitoring would be based on interventions and annual targets set at various levels. Henceforth.767
. Financial management. The table 18 below was computed using the established norms to highlight the status of service delivery units for the purpose of guiding the implementation of KEPH.909.3. the need to rationalise facilities cannot be overemphasised Table 18: Service Delivery Units Needed and Available by Level of Care
Province Central Population 3. 3. District health planning.804.078
7.care. Standards and quality assurance.103.297
5 5 3 3 1 1 5 5 8
2. Human resources management. The systems required to support the KEPH initiative include the following: Interface between services and community.902. The focus is on function as opposed to physical level. it can be seen that no service delivery units at the community existed at the start of KEPH despite the critical role which has been assigned to it.782 Service Delivery Units Status L1 R 782 E G R 560 E G R 1021 E G R 513 E G R 238 E G R 961 E G R 1580 E L2 391 372 19 280 334 -54 510 692 -182 256 381 -25 119 68 51 480 333 147 790 1006 L3 130 89 41 93 42 51 170 80 90 85 54 31 40 12 28 160 117 43 263 161 L4 39 65 -25 28 64 -36 51 65 -14 26 58 -32 12 8 4 48 98 -50 79 100 L5 4 4 3
2. For equity to be achived across the country. Commodity supply chain management. health planning would introduce a bottom-up approach in which the community would identify their health intervention needs to be incorporated into district plans and form the overall national health plan.
use of skilled birth attendants and health education. It needs to be emphasised that having HIV/AIDS services. Stage 4 is the adolescence stage. The services for the elderly again.5 Performance Review of KEPH and AOPs An operational performance review of the Annual Operational Plan 3. 2006 NB: R=Required.4 Awareness of KEPH
At Level IV of public facilities. district services 34. MOH. for youth friendly services. e. the survey revealed lack of youth friendly services in nearly all facilities visited. in the services addressing the needs of stages 4 and 6 of the human life cycle. Glaring gaps are.853. the matrons and registered clinical officers were found to be well versed with KEPH.30% and health centres and dispensaries got 20.3. E=Existing. Health services for stage 6 of the human life cycle.74% to implement the health services. In AOP 2.Western
3. the elderly. Youth friendly services include having special time or day for the youth as well as facilities and staff specific to the youth.125. In private and faith-based facilities. Table 19 shows that Tertiary services represented by National and Provincial services received on-budget allocation of 44. They however added that the idea had been sold to them. delivery and new born up to two weeks. was conducted jointly by the MOPHS and MOMS.96%. 2007/2008. was also also found to be lacking. In terms of service delivery indicators reflected in table 20. The focus was on the provision of ITNs to pregnant women. 3. it was established that the Medical Superitendents and the matrons in charge of maternity were most aware of KEPH. women 25
. antenatal and postnatal care.361
G R E G R E G
-216 385 196 189 3213 3382 -169
102 128 94 34 1071 649 422
-21 39 68 -29 321 526 -205
8 4 4 32 20 12
Norms and Standards for Health Service Delivery.3 Implementation of KEPH
KEPH was to be rolled out in phases during the NHSSP II starting with the first stage of human life: pregnancy. At Level IV. G=Gap 3. it was mixed reaction: some had heard about KEPH and even participated in AOP planning actvities while other had not heard of it. The rest of the staff had heard about KEPH and had some vague understanding but lacked in-depth understanding of it.g. there was a downward trend. however. No allocation was specifically made to Community at Level I.3.3. are not limited to making drugs for hypertension and diabetes available but includes raising awareness on healthy life styles and having equipment for screeining for these conditions available at appropriate service levels and encouraging people to go for screening. Only one facility had clear youth programmes. treating STIs and so on do not in themselves amount to youth friendly services. This has been covered reasonably well. Drugs for diabetes and hypertension are very expensive and are not part of the Health Centre kit from KEMSA. family planning services. 3. Percentage of Women of Reproductive Age getting family planning commodities was 43%.936
32. but resources were not made available for implementation.
076.258.0 7.0 44.384.3 0 0 0.487. Against this background.227.3 0 0 1.428.4 25 394.9 8.3 754. the table below focuses on the strengths.40 AIA 73.0 TA Total 9.0 0 0 0.013.00 0.291.689 ARV Clients* Malaria* (Mn) 60.715.974. delivery by skilled staff in health facility was 37%.3 688.9 115.0 0 0 0.569.
.00 0.6 2.7 1 0 74. Corresponding figures for AOP3 was 37%.4 3.8
Source: AOP 3 Performance Report.3 2.776.00 12.322.7 4.00 7.7 7.8 2.7 34.401 115. structure and organisation of the delivery of healthcare services in Kenya.6 SWOT Analysis of KEPH
The KEPH system is a major shift in the philosophy.4 999 1. Table 19: Actual Allocations by Levels and Category for AOP 3 2007/2008 (KES Millions)
Category LVI .4 7.attending four antenatal clinics was 52%. MOPHS
Table 20: AOP3 (2007/08) Performance Review Report: Service Delivery Indicators Service Indicator NHSSP II AOPI AOP2 AOP3 NHSSP II 2010 Baseline Target % WRA getting 10 13 43 37 60 FP Commodities % women 54 56 52 39 80 attending 4ANCs % delivery by 42 18 37 28 90 skilled staff in HF % <1year 58 59 80 70 100 immunized %< getting 33 15 34 44 80 vitamin A TB cases* 108.981.15 120.0 3.3 0 488. 39%.5 3.7 488.008.7 258.581.3
Sub-total (On-budget) % allocation Donors Cost sharing Sub-total (off budget donors + Cost sharing) Grand Total
Source: AOP 3 Performance Report. weaknesses.0 Comd 886. Facts & Figures 2008.1 12.0 Grants 6.4 0.5 Infra 150.6 0 12.487.District Services LII/III – Services Rural Health PE/HRH 1. Economic Survey 2008.026 8.971.6 12.185.457.60 1.3 5.3 27.3 2.2 7.689 8.5 28.3.6 731.6 Vehicl 0 0 0 3.00 74.0 3.30 488. conduct.969.4 1.3 3.841. opportunities and threats which face the system.278.7 9.0 O&M 809. MOMS.8 1.149.006.1 461.848.234 115.801.392 9. and immunization for less than one year was 80%.Provincial Services LIV .0 5.National Services LV .595.7 1.7 956.6 13.4 124.7 0. 28% and 70% respectively.841.391.8 5.00 3. 3.6 0.
STRENGTHS Anchored on the NHSSP II 2005-2010 Implementation backed by AOPs Governance structures are clear and distinct Joint roles of Government. budgeting. Private Sector fully recognized Backed by SWAp initiative for one plan.7% Inadequate financial allocation to the health sector due to budgetary constraints Failure to meet key health indicators identified in the NHSSP II Failure to institutionalise the KEPH systems among all the stakeholders Failure to design and implement equitable healthcare financing mechanism
OPPORTUNITIES Political goodwill to improve and expand health services to all citizens including the poor Recognition of health sector reforms initiatives in all major policy and planning documents including NHSSP II.
. has been to a large extent successful. one funding and one M&E Norms and Standards established to facilitate implementation across board Financial costing for KEPH and Non-KEPH services done and projected to cover entire plan period. FBOs. Collaborative development partners and willing local health sector partners
A synthesis of the SWOT analysis reveals critical issues and challenges affecting all the three components of the KEPH system. NGOs. costing and computation of required resource quantities is a big challenge The first phase roll-out of KEPH services. Medium Term Plan2008-2012 and Vision 2030. 2005-2010 Identified key health sector indicators to help monitor achievements
WEAKNESSES Preparation of AOPs of various facilities and districts is still problematic Coordination of health sector activities as envisaged under SWAp has not been achieved Harmonization of financial projections components envisaged under KEPH and the traditional allocations with respect to expenditure categories and type has not been achieved Shortage of trained staff to implement some aspects of KEPH such as planning. but subsequent rollouts were never tied to any particular AOP and therefore not clear to measure achievement There is not a clear-cut consensus on what constitutes a minimum package of healthcare THREATS Slow down in economic growth from a high of 7% in 2007 to a low of 1. MCH/FP. Stakeholders. These challenges are addressed in the next section. Donors.
human and infrastructure resources needed to provide these expectations. provincial.1. The roll out of the KEPH systems was to be done in phases during the life of the NSHSSP II. and Service delivery support systems. for primary care facilities Level II and III.1 Human Resources The norms and standards for the human resource have been derived taking into account the types and number of staff needed at each Level. attention was paid to the first two life cycles cohorts namely: pregnancy/new born and early childhood.4
Challenges in Healthcare Delivery System
The challenges facing the healthcare service can be viewed in three categories namely: Service delivery. 3. 1.4.3 above.1 Service Delivery
The services to be delivered at each Level of healthcare have been outlined in chapter 1 sections 1. As part of service delivery strategy.1. for adult age group who needed mainly curative and rehabilitative healthcare.4.2.1. Service delivery standards relate to the expectation of each level of care with regard to service delivery. efficiently and sustainably offer service delivery packages. and adult age group as indicated in section 3. drugs for diabetes and hypertension are very expensive as they are not part of the KEPH package.8 for Level VI facilities.4.2 Service Delivery Resources
Resource inputs for the healthcare service delivery have been considered under four categories of Human capital (staffing). The expected number will then be determined by the
.5. Improvements in subsequent AOPs were made and the current one. infrastructure.3. gave their inputs into the plans to form integrated district. 3. However. for the year 2009/2010 has fully incorporated a bottoms up approach in which plans from the lower Levels have been integrated with those of higher Levels to form Integrated district. Service delivery resources/inputs. During the first year. the private sector has not been involved in all the districts and facilities sampled. Norms and standards are statements of inputs which are necessary to ensure efficient and effective delivery of health services to the people of Kenya. Financing and commodities. The first AOP was prepared to cover 2005/2006 financial year. The roll out for the Maternal Child Health and Family Planning for the first cohort has been successful and during the survey all facilities sampled reported offering the services according to their Levels. The objective was to ensure that all stakeholders in the health sector.6 for Levels IV facilities. departmental and district plans. However there were several challenges of capacity to undertake such massive assignments throughout the country. services and targets were identified to guide service delivery for the coming year. provincial and national plans. The economically challenged in this group therefore cannot afford the medicine. However.1. 3. both in the public and private sector.7 for Level V facilities and 1. Annual Operational Plans were established in which all interventions. AOP 5. The Government has already established norms and standards which are used in determining whether these challenges are being overcome or not. 1. Service delivery norms refer to the quantities of these resource inputs required to effectively.
Only some faith based hospitals were found to employ professional medical staff. Lack of maintenance systems to ensure serviceability and functionality of existing infrastructure. information. 3.4. the infrastructure norms refer to the minimum quantities. Availability and serviceability of some basic infrastructure in health centres is below 100% which has been achieved in district and provincial hospitals.expected workload based on the activities to be performed at that level.4. 3. Training opportunities for both pre-service and in-service staff.
. equipment which had been donated for Ear. Health centre facilities had major challenges in having maintenance programmes for their infrastructure.2. They are meant to help the health professionals who are enlisted as visiting consultants. It is worth noting that in one mission owned facility. Nose and Throat treatment and two theatre operating rooms have been lying idle because the facility could no longer afford to employ qualified doctors to make use of them. In the private sector facilities sampled. The challenges facing the human resource in the healthcare delivery include: Overall staff shortage with respect to workload. Shortage of skilled and specialized staff. communication technology and transport. Table 8 shows the position of maintenance arrangements found in the sampled facilities during the baseline survey. 11 and 12 show the position of staff deployment vis-à-vis the minimum norms established for the KEPH system of healthcare service delivery in the public sector facilities. effective and sustainable health service delivery. clinical officers and medical technologists in various health fields. Retention of specialist doctors in the service. regular staff are only employed at lower cadres like nurses.2. Shortage of skilled personnel to use and maintain the infrastructure. equitable. Urban and regional staff distribution bias which makes the rural areas and certain regions be disadvantaged in service delivery. among other questions. These should integrate harmoniously with other inputs particularly the human resources to ensure efficient. population to be served and the time each activity takes. The challenges facing infrastructure are many and include: Shortage of some critical infrastructure due to financial limitations. equipment.3 Commodities Availability of commodities comprising medicines and non-medical supplies is a major challenge in all public facilities sampled during the survey.2 Infrastructure The infrastructure required at different levels is guided by the type of services offered and the human resources required at the health facility. The table below shows the response of clients who were asked if they had received all the medicine prescribed at the facility. The four components of infrastructure norms include buildings.
Tables 10. As with the human resources.
availability of medicine was better in health centres. KEMSA has never been able to service requisitions from the health facilities in full making usage of the allocations an academic exercise rather than a reality.5 39.5 99 69. Records at KEMSA were said not to be very accurate because some facilities were informed that they had exhausted their allocation when on the ground that was not the case.5% and 38.4 28. Low investment in health by government. 85. However.7% and 72.7 97 72.4
Provincial hospital District hospital Health centre Faith based Private
96 73 93 100 97
31. It is composed of individuals who have their own money and pay for the health services upon receiving it. Some of the challenges in this area include the following: The current practice whereby public facilities are required to only source their supplies from Kenya Medical Supplies Agency (KEMSA) has created a monopoly whose efficiency and effectiveness are lacking. faith based and private facilities where 69. households (35. The main contributors to health expenditure are.5 90 38. (i) Out of Pocket Expenditure This is mainly the user-fees individuals pay to the health service providers at the time of receiving health service.1%) and others (0. cash given out by individuals to relatives or friends who are in crisis.5% of customers who visited provincial and district hospitals respectively received all the medicine at the respective facilities.7 39. It is also referred to as household expenditure. Key challenges in financing healthcare include: Large out of pocket expenditure which cannot be budgeted or programmed for. Tying up money allocated for commodities at KEMSA during the financial year. donors (31%). During interviews in the facilities. local foundations (0.4.4%) according to the 2005/06 figures.3%). but need medical services for which they don’t have money. private companies (3.7% received the medicine prescribed.4
Source: This Survey Only 23.9%). Inappropriate allocation of financial resources within government health budget. KEMSA has adopted the “push” practice and thereby forcing the facilities to receive medicines which they have no immediate use for.2.8 56 60. Government (29.5 63.6 35. Out of pocket funds are therefore 30
.7 Said facility staff were friendly Were very satisfied Were satisfied with the services 63.2%. the stakeholders lamented that on average they receive between 30-60% of requisitions submitted to KEMSA.4 Financial Resources Financing healthcare has remained a challenge to the Government of Kenya for a long time.7 60.
3.2 100 85. Inefficient and less effective NHIF. organised fund-raisers to raise money for those who are faced with exceptionally high medical bills for specialised treatment (or just bills they can’t afford) and finally.Table 21: Customer satisfaction with service delivery
Number of clients sampled 51 52 91 28 33 The percentage of clients who: Agreed they Received all were given the medicine sufficient time prescribed at to explain their the facility health issue 92 23. Low public awareness on the need for health insurance.3%).
0 in 2007/08.409 2.350 1.542 Source: MOMS Facts and Figures 2008.7 5.9 5.036 10.not available in such a manner that it can be budgeted for. Investing in Health for Development.A.5 1.417 19.6 6.3 6.7 5.659 2.
% of Total 52. Annex C: Health Expenditure trends in selected countries. Table 23: Total Health Expenditure as % of GDP for selected countries S/# Country 1998 1999 2000 2001 2002 1 Ghana 5.8 4. allocation of the limited financial resources for different uses within the health sector has not been optimal and remained a challenge. In terms of US dollar.4 14.7 4.2 5.Total Health Expenditure as % of GDP S/# Country 2001/02 2002/03 2003/04 200405 2005/06 2006/07 2007/08 1 Kenya 1.2 6 Senegal 4.667 Drugs and medical consumables 1.5 4.798 8.6 2 India 5. 2006 N.1 6.1 3 Mexico 5. Per capita expenditure on health has been fluctuating but slowly increasing from KShs 395. It is also not the desirable option as falling ill does not always coincide with the availability of funds.4 3.756 1.1 4 Nepal 5.767 Purchase of plant and equipment 95 15 81 596 527 Kenyatta National Hospital 2.074 2. Fact and Figures.7 5.7 Source: Government of Kenya.0 3.765 21.481 1.2 4.1 4.101 9.6 5.7 5.635 1.6 1.5 1.5 1.5 1.716 1.257 1. = Not Available The challenge is not limited to the amount of funds available for health expenditure.100 Moi Teaching and Referral Hosp 422 458 458 714 747 Total Recurrent (Gross) 14. Ministry of Health expenditure as a percentage of GDP has been equally low as detailed in the table below: Table 22: Kenya . this is from $6.2 5 Indonesia 2.439 17.1 8. the Government has had difficulty in allocating “adequate” funds to the Ministry of Health.2 6.5 2.7 1.327 3.8 3. (ii) Government Health Expenditure Allocation Over the years. Table 24: Actual Recurrent (Gross) Expenditure by Economic Category (KShs million) Details 2002/03 2003/04 2004/05 2005/06 2006/07 Salaries and other personnel 7.0 6.866 2.405 15.858 3. The table below illustrates how funds have been applied for different uses in the Ministry of Health over a period of time.347 Transfers and subsidies 1157 1455 1563 1.5 100
.50 in 2001/2002 to KShs 983.407 11.7 6.8 respectively.1 Source: Tough Choices.6 2.388 Other operations and maintenance 1. WHO.7 11. way below the WHO recommended figure of US$ 37 per capita. 2008 This can be compared to health expenditure trends in other countries and the table below summarises the information.7 7. Ministry of Medical Services.28 to $13.285 1.6 5.2 2.4 5. It can be observed from the table that many other countries are investing in their citizens’ health more than Kenya.
public and private sector insurance.655 23.000 17.544 % 37 31 7 9 12 4 100 2007/08 30.000 860. it contributed KShs 2.361 4.541 9.41 100. making insurance contribution to be KShs 6.000 1.It is important to recognise that in the NHSSP II.835 6.235 3.207 11.016 to total health expenditure while private insurance contributed KShs 3.939 2.570.5% is categorised as others.152 99.000 58.713. NHIF contributed KShs 2. this averages 37% and 31% respectively. Of all the insured people.887 6.700.27 43.4%.9% of people with health insurance contributed KShs 3. 83.27 (see the table below) as compared to the Ministry of Health’s 61%.200.000 240.8% are covered by NHIF. 0.882 % 37 31 7 8 12 4 100 2008/09 33.720 89.44% as compared to the ministry’s paltry 11.6% by community insurance schemes.41 9. Such a comparison would however not be only interesting but also revealing.000 5. repairs and maintenance at one of the private hospitals amounted to 45.44% 1.460.259 7.340.554 4. Table 26: Expense Structure for Private Facility
S/# 1 2 3 4 5 6 7 Details Personnel.482.457 4.797 10.460.000 8.48 0. Prudent resource allocation remains a challenge to the public health sector.185 30.000.570.8% of all the persons with health insurance.849.317 6. repairs and maintenance Consultants Medicines Other supplies Printing and Stationery Workshops and Planning Others (Plant & equip.00 Total
Source: This Survey (iii) Health Insurance Health insurance in Kenya has two components.1%.278 % 37 31 7 8 13 4 100 2009/10 37.828 7.160 3.712 20. Medicines and other supplies constituted a whopping 43. Table 25: Projected Cost of KEPH by Expenditure Categories (KSH Millions)
CATEGORY Salary Drugs and supplies Lab tests & other investigations Bed and meals Allocated overheads M&E Total annual cost 2005/06 23. whereas in the Ministry this only constituted only 2.016 while private insurance covering 19.030. etc) Total Expenditure 2009 Expenditure (KShs) 23.000 % of Budget 45. In the table below. It is worth noting that whereas NHIF covers 83.713. Personnel.460.797 7.000.075 3.412 81. indicating strong growth and development.025 74.645 64. 7. 12% by employer insurance schemes. private individual and community insurance.632.597 7.632.729.235 5.809 12. Plant and equipment at the private hospital was 9.367 5.913 % 37 32 7 9 12 4 100 2006/07 27.659 % 37 31 7 8 12 4 100
Source: NHSSP II 2005-2010 Further comparison can also be made to the cost structure of one private facility sampled during the survey despite the fact that it is a small entity compared with a whole Ministry. 32
. the projected cost structure of implementing the KEPH system in the categories of salaries as well as drugs and supplies was given much more weight than the other categories.849.236 25. Public sector health insurance is National Hospital Insurance Fund (NHIF) on the other hand private sector health insurance is composed of employer insurance schemes.9% by private individual insurance and 0.4% of the total expenditure.277 27.
and this is so when the fund only pays for bed nights. It is however a very inefficient and less effective institution as can be seen by the fact that it only contributed 3. 3. Between the public facilities and the private ones.7% to total health expenditure in 2005/06. Lack of transparency and accountability to attract confidence of all stakeholders. Management of a system as dynamic as KEPH and which requires a lot of flexibility is uniquely challenging. In the case of healthcare service delivery. partners and stakeholders recognize each others’ role and are prepared to work harmoniously for the common good is a key challenge.5 Service Delivery Support Systems. Shortage or lack of qualified staff with management capacity and ability to motivate staff and offer leadership. Quality management system is at the core of acquiring inputs. the challenge is to keep the private sector informed of changes occurring in the health sector which require their participation. Inadequate capacity for knowledge management to ensure production. any new initiative can only succeed if it wins the confidence and ownership of stakeholders. The revenue – benefits payout ratio has remained very low. reportedly at 50%. processing them into final products and getting the finished products to where they are required to get the job done. commodities and infrastructure in a timely manner. Shortage or lack of skilled manpower to enhance utilization of the support systems. During the focus group discussions. 33
. preservation and dissemination of knowledge and enhancing of best practices. Indeed. All of them claimed they are never invited into such meetings particularly those dealing with annual operational plan activities. The reforms currently going on in the health sector remain much of a subject for senior officers in the public health sector while leaving out their juniors. It is faced with many challenges including governance and management. Enhancing governance and management structures to ensure that all actors. The fact that NHIF is mandatory for all in formal employment has probably worked against the growth of private health insurance in Kenya. Communication and information flow is a problem both within the public sector and between the public sector and the private sector. It is a mandatory health insurance scheme for all Kenyans in formal employment. Private health insurance has remained relatively small in Kenya. KHF indicated that they are not represented at the Health Sector Coordinating Committee where annual operational plans are approved. it clearly emerged that organizations operating facilities run by private and FBO have not been incorporated into various forums where health plans are being articulated. It was very disappointing that most staff members do not know of the KEPH initiative. monitoring and evaluation so as to deliver the services required from them.2. financial management.4. the systems will help in getting the inputs such as money.
The challenges facing the healthcare service delivery in this category include the following: Shortage or lack of the right systems to ensure that their deployment and application can generate the desired results.NHIF was established primarily to provide Kenyans with access to healthcare. drugs. Within the public sector. It will also ensure that the resources are better managed in terms of planning. this could be seen during the focus group discussions when most members revealed that they had never seen the documents associated with KEPH and its implementation. human resources. even at the national level.
. It was obvious that the capacity of the current staff to collect.
Records and data management capacity at the facilities are not up to the required standards. analyze and manage data was inadequate. In many facilities. the survey was hampered by lack of readily available records.
Thus the probability to find a space in the health facility for an inpatient in Nyanza is the highest in the country compared to all the provinces including Rift Valley. while North Eastern with a population of 1. It is obvious that the understanding of these changes and the strategies already put in place to implement them have not been communicated or explained to all health workers.000 population. with a population of 5. non-governmental and the private organizations is about 48% in comparison to 52% owned by the public sector.0
4.000 and 18. 4. Although they are supposed to participate in meetings which are arranged to help in the implementation of the reform process.2 Reforms in the Health Sector
The reforms which have been going on since the 1994 when the Kenya Health Policy Framework document was published have introduced a paradigm shift from what the players have previously been used to. In terms of distribution. The survey found no evidence of any private facility with an annual operational plan prepared in the format suggested by the KEPH requirement. they do not attend such meetings. The Health Centres in particular have dual responsibilities to the two ministries.1
Organisation of the Healthcare Delivery System
The splitting of the Ministry of Health into two ministries of Medical Services and that of Public Health and Sanitation has brought with it challenges of coordination which are crucial for the activities of healthcare delivery to be handled seamlessly. when the staff are involved in preparing annual operational plans and setting targets they are not aware that what they are doing is part of a bigger picture of the reforms embracing the KEPH system and its implementation.034. 4. majority of staff members in the field are just not on board at all. they fall directly under the Ministry of Public Health and Sanitation and in the referral system they have a reporting regime to the Ministry of Medical Services which is in charge of district and provincial hospitals.402. on the ground.900. For administrative control.8% with less than 5 kilometres to the nearest facility. many times because they are not aware. Nyanza.000 population compared to Rift Valley with a population of 9.443.4.3 Distribution of Health Facilities
The total number of health facilities owned by all the players in the private institutions including faith based.3% within 5 kilometre of a facility. Nairobi which had a population estimated at 3. Thus Nairobi residents would spend less money and time to reach a facility compared to North Eastern and the rest of the provinces. In the public sector where these changes originate and domiciled.000 in 2007 had the highest population of facilities at 79.313.3 per 100. For example.800 had the least population of 14. had the highest number of wards beds and cots of 30. They are therefore not on board with the new changes taking place.1 beds and cots per 100. 35
. The private health sector which is also part and parcel of the healthcare delivery system is not a full participant in the reform process. This arrangement requires extreme understanding of the players on the ground because any small misunderstanding can seriously affect the working arrangements particularly in the referral system and even information and data flow.
713.3%. local foundations and others.849. Level IV by 33 while the health centres had a shortage of 52. total health insurance spending amounted to KShs 6. With a population of approximately 37. Sources of financing the health sector include the government (representing the public sector budget allocation). This means that 24 could have been deployed elsewhere in the country where the staffing norms were not met. this did not mean that they had the desired number in relation to the workload as dictated by the catchment population. The survey revealed that overall there was a shortage of staff in most facilities as computed by the facilities. 4.4.460. how to allocate the limited resources more appropriately among expenditure categories and how to raise more domestic resources for investing in the health sector. Insurance health spending is divided into two.482. private sector.2%. a total of 120 medical specialists were required but only 49 were actually in post. The large proportion of household payment is unpredictable and should be reduced to the minimum or eliminated altogether.570.324.518.000 then.6 KEPH System Introduction of the KEPH system articulated healthcare delivery by reclassifying the health facilities into six Levels and their functions.607 while Total Health Expenditure (THE) in the same period was KShs 70. and THE as a percent of total government expenditure was 5. households. Some facilities however did not even meet the minimum threshold.000.4%) was from private health insurance companies. In 2005/06.957. 5. While some facilities may have met the minimum threshold. Kenya’s healthcare spending is therefore below the WHO recommendation by about US$ 7 per head. government spending on health was 8% of Total Government Expenditure. It should be noted that in 2001/02. The World Health Organisation (WHO) Commission on Macro Economics recommends a per capita health spending of US$ 34 for financing essential package for health services. NHIF and Private Health Insurance. (59. For example. Each facility at every level was defined by the catchment 36
. It was noted that shortage of staff increased at the lower facilities.6%) was attributed to NHIF while the remaining KShs 3. 4.030. According to the National Health Accounts. while a total of 75 medical officers were required yet 91 were in post. which is below the Abuja Declaration target of 15%.5 Health Financing From the recommendations of the Abuja declaration of 2001 and the World Health Organisation. in the sampled Level V facilities.4
Norms and standards have been established for minimum staffing at various levels of public health facilities. The challenge therefore remains how to bridge this resource gap.807.2% was therefore a reduction. Total Government Expenditure in the period 2005/06 was KShs 401.729 of which KShs 2. For example staffing for nurses at Level IV facilities surpassed the norms by 313. THE per capita was therefore KShs 1. the conclusion to be drawn is that health sector has been under-funded in Kenya. households paid the biggest proportion of the health budget at 39% compared to the government portion of 29. private health insurance has the potential to contribute more to healthcare spending if the playing ground were made more even (contributions to NHIF are mandatory).722.987 (approximately US$ 27).3% and the private companies’ portion of 3.016 (40.632. donors. As can be seen from the role it is already playing.
7 Challenges The reform initiatives currently underway in the health sector and their implementation face considerable challenges which must be addressed for the results to be positively felt by the consumers who are the real beneficiaries. Secondly. The challenges have been categorized into three areas. the resources or inputs required. the range of services to be offered. there are challenges associated with service delivery resources or inputs required to be used in the delivery of the services. These include the phased roll-out of the range of services which started with maternal child health and family planning which has registered good success. Thirdly.population. Other phases have not recorded much success. and the support systems required to help in the management of the entire system. When KEPH recognized the Community as the basic unit and the first level of healthcare delivery and formalized the organizational structure to mobilize the community to take charge of their basic health needs. the implementation of KEPH system is faced with considerable challenges. Henceforth. there are challenges facing the service delivery support systems necessary to help in the management of the activities in the service delivery and the utilisation of the resources. In the first instance there are those challenges which affect the service delivery. However. it brought a paradigm shift from the previous scenario.
. the principle of meeting basic health needs and rights of individuals equitably was enshrined in the guiding principles of healthcare service delivery of the government of Kenya. 4.
5. 5. Health investment in this area has a huge knock-on effect on poverty and economic development and thereby empowering communities to meet their basic needs including health insurance. 5. 5. Facilities should be encouraged to bring such policy changes to the attention of all their staff. money and effort so as to bring down unit cost of interventions. There is need for intra-provincial and inter-provincial including urban-rural staff redistribution to bring about a more equitable deployment of available staff than what is the case now. This is essential in addressing the challenge of idle capacity occasioned by mismatch between the resources available and the capacity to utilise the resources for optimal productivity.4 Rationalisation and Deployment of Human Resource Increased investment in the health sector should include hiring more staff and staffing norms should be adhered to as much as possible.3 Rationalisation and Distribution of Facilities The Ministries of Medical Services and Public Health and Sanitation should consider rationalising the distribution of health facilities across the country in terms of population.2 Improve Efficiency and Effectiveness Service delivery is about achieving results and meeting targets set in the Annual Operational Plans of various health facilities. Staffing in Level III and II (Health Centres and Dispensaries) should particularly be paid special attention if access to healthcare is to be achieved. it is important that more attention in terms of organisation and resources should be given to the Level I service delivery units than what is given at present.7 Decentralisation and Role of Government Organisation and Management structure which was designed and currently being implemented to deliver the KEPH system has created a very fertile ground for full blown decentralisation of the 38
. 5. With a population of 46% living below the poverty line (50% rural and 33% urban). Consideration for any additional resource requirement for such changes need to be discussed and/or made available to the facilities as appropriate. 5.5 Capacity Utilisation Training of staff to acquire the right skills to enable them perform their duties is critical to enhance capacity utilisation. distance to the nearest facilities and the number of ward beds and cots available per region. It is also about meeting these targets through eliminating waste and realising savings in the use of resources such as time.0
5.6 Consultation and Communication Any policy changes should be properly and adequately articulated and information passed down to all facility levels as well as stakeholders in the public and private sectors. Deployment and utilisation of service delivery support systems will bring about effectiveness and efficiency in the implementation of the KEPH system.5.1 Prioritization of Service Delivery to the Poor and Level I The KEPH system has recognised households and communities as the most important Level in reversing the downward trend of health indicators.
5 A body charged with regulating and costing of health benefits such as Health Benefits Regulatory Authority should be established. reflecting the general consensus in the private sector. 5. Those who require additional healthcare should pay for it.8 Alternative Approaches to Healthcare Financing Healthcare financing is currently a subject under very intensive discussion both in the government and private sector. 5. However.8. 5. in this document we put forward suggestions which could be taken on board.7 Expenditure projections for the KEPH system were made on the basis of allocating an average of 37% and 31% for salaries. 5. 5. 5.8.3 The move towards universal health coverage should make it mandatory that all Kenyan residents enrol with at least one health plan.8. It is therefore appropriate for the Government/Ministry of Health to entrust healthcare delivery to semi-autonomous public and private sector health facilities.8.8. 5.4 There is need to define and cost the a minimum health package to which each and every Kenyan resident is etitled.health care delivery system. It should concentrate on the 46%. leaving below the poverty line.2 Government should allow the introduction of multiple health plans to be administered by several health insurers/purchasers.6 Repurpose existing consumption tax to plug the whole in the financing gap which may be occasioned by meeting social responsibilty for the poor.8.8. It is recommended that this balance be achieved as a way of repurposing expenditure allocations in the health sector budget.
. Already the Government has put forward a position paper on the way forward. comprising about 11 million indigents and 9 million poor. The role of the Central Government should be confined to policy formulation and regulation of the health sector 5. drugs and supplies respectively.1 Government should maintain its social responsibilty to the poor with respect to healthcare financing.
Thiong’o Dr. 29. Kisumu East. Monica Hospital
Matron in Charge Matron in Charge Administrator RCO Matron in Charge Health Administrative Officer Medical Superintendent RCO in Charge Nursing Officer RCO in Charge Nursing Officer Nursing Officer Matron In Charge Nursing Officer Administrator/Matron Charge Nursing Officer RCO in Charge Nursing Officer Nursing Officer
. 17. H.ANNEXES
Annex 1: Persons Interviewed
1. H. 26. Mary’s Hospital St. St. Paul Omwandho Dr. Nairobi. 22. Machakos Nairobi Nairobi. 2. Nairobi. Esther Getambu Dr. 18. 31. 21. Nicholas Muindi Faith Kavata Damaris Musyoka Regina Muthusi Mrs Stella Mwongela Ms Margaret Wanjohi Mrs Gladys Owira Mr. Bahati Dr. Mary’s Hospital MoPHS MoPHS Jalaram Home Jalaram Home MoPHS MoMS MoMS MoMS MoPHS MoPHS MoPHS MoPHS MoPHS MoMS Bishop Kioko St. Anthony Momanyi
MoMS MoPHS MoMS City Council Nairobi MoMS MoMS St. 14. 16. Micheni Mr. 28. St. 15. C. 4. 33. Irene Muchoki Lydia Kiplagat Mrs Phoebe Ageng’o Mr. Name Dr. District Hospital Machakos Kisumu Nyahera. 11. 19. Elkana N. Monica Hospital MoPHS MoPHS MoPHS MoPHS of
Kisumu Kisumu East Embu Nairobi. 23. Langata H. District Hospital Kisumu East. Ojwang Lusi Mrs Jane Raburu Dr. Langata H. Moseti Mrs Akelo Mr. C. Rabuor H. 27. Robert Ayisi Dr. Deputy Director. Kenya Medical Association Provincial Director of Medical Services District Public Health Nurse Provincial Director of Medical Services City Medical Officer of Health Medical Superintendent Head. 6. Nyahera. Mary’s Hospital Nairobi. 32. Onguti Dr. 20. C. District Hospital Embu. 3. Andrew Suleh Position Chief Executive Officer. 8. C. 13. Kioko Dr. 12. 25. C. Muli Angela Katundu Mr. C. Kisumu Kisumu Rabuor H. 10. 30. Jotham N. 5. Kaviani Kaviani Mitaboni Mitaboni Machakos District Hospital Machakos. Kennedy Auka Dr. 24. Charles K’Otung’ Mr. John Mwangi Ms Esther Nyamusi Ms Bwire Mr. 34.
Dr. Policy and Planning Division Organisation Kenyatta National Hospital Kenyatta National Hospital MoMS MoPHS MoPHS MoMS Location Nairobi
Nairobi Nairobi Kisumu Nairobi
7. 9. Samuel Ocholla Dr. Walter P. Mwendwa Mr. Konya Fr. Finance and Administration Provincial Director of Medical Services Provincial Director of Public Health and Sanitation Provincial Director of Public Health and Sanitation Medical Superintendent and Chair.
75. Muhavi Dr. Centre Njoro H. Centre Njoro H. D. Hospital C. G. P . I . Hospital Molo D. P. W. Centre Mercy Mission Hospital Mercy Mission Hospital Mercy Mission Hospital Valley Hospital Valley Hospital Valley Hospital C. Hospital Molo D. Kihangare Mr G. G. Lumbanga Ms C. D. Hospital C. Charity Mr H . Kenarja Mr J. Obwanga Mr John Kabochi Ms M Kamau Dr. Therapist C officer Radiographen Engineer Physiotherapist Nutrtionist Pharmacist SNO Nursing Officer Nursing Officer Nursing Officer Nursing Officer Nursing Officer Nursing Officer Nursing Officer HAO Nursing Officer Nursing Officer Matron in Charge Nursing Officer Nursing Officer Chief Admin/ Med Sup Deputy Chief Admin Matron Matron Matron HRM&IR Nursing Officer Nursing Officer Health Administrative Officer Nursing Officer Nursing Officer Nursing Officer
MoPHS Kenyatta National Hospital Bishop Kioko Nairobi West Hospital P G H -Nakuru P G H -Nakuru P G H -Nakuru P G H -Nakuru P G H -Nakuru P G H -Nakuru Molo D. 73. 77. Mwangi Dr.Centre Rongai H. Nyangan Mr A. Hospital Molo D. Hospital Molo D. Hospital Molo D. D . Hospital Rongai H. Hospital Molo D. Ochula Ms R. Tallam Mr F. Amit Singh Dr. Nyamu Ms Martha Ms Mwachunya Mr Mose Ms Mwajuwa Ms Jane Ms Binti
District Public Health Nurse Planning Manager Manager Chief Financial Officer Med Sup Nursing Officer Nursing Officer Nursing Officer Nursing Officer Nursing Officer Med Sup Occ. Njuguna Ms L. 43. J. 74. G. 40.G.Mwangi Dr.G. 37. Hospital Molo D. Chemutai Ms M. 72. Hospital Pandya Memorial Hospital Pandya Memorial Hospital Pandya Memorial Hospital Msabweni Dist Hospital Msabweni Dist Hospital Msabweni Dist Hospital Msabweni Dist Hospital
Machakos Nairobi Machakos Nairobi Nakuru Nakuru Nakuru Nakuru Nakuru Nakuru Molo Molo Molo Molo Molo Molo Molo Molo Molo Molo Molo Rongai Rongai Njoro Njoro Njoro
Mombasa Mombasa Mombasa Mombasa Mombasa Mombasa Mombasa Mombasa Msabweni Msabweni Msabweni Msabweni
. Kivui Mr.35. 41. Centre Njoro H.G. Mutura Mr J. 69. Maganga Dr. 66. 38. 63. 62. 68. Hospital C. G. 42. Mugenya Mr. Mwangi Mr M.M Kimani Mr M. 36. 65. E. 64. Ogendi Ms Ziporah Ms G. Kamau Ms F. 78.
Mrs Anne Mutunga Mrs Ludmila Shitakha Fr. Kariuki Mr D . 39. 71. Chepkirui Ms T. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61. Daniel Muvaa Mr.M. Mwaura Mr G. D. 67. Hospital Molo D. P. Hospital C. 76. Kambu Dr. P . S. Hospital Molo D. 70. P. Gikonyo Mr Rotich Bargoye Ms C. P. Ngome Mr Jacob Chelimo Mr G. Wanjiku Mr. Hospital Molo D.
Mohammed Kombo Dr. Mohammed Harsan Dr. Specific objectives of the study are to: a) b) c) d) e) Establish the type and distribution of existing physical resources available for healthcare Establish magnitude and sources of funds available for healthcare services Identify gaps and challenges in the provision healthcare Identify alternative ways of improving healthcare delivery through Public Private Partnership. affordable and accessible to all Kenyans. Study. although will not be limited to: a) b) c) d) Review relevant documents for health sector Identify facilities and stakeholders to be visited Prepare tools for gathering data and information from the facilities visited Carry out field work in the selected provinces and districts 42
. 2. 3. Mutinda Kisingu Ms Nduati Mr. 87. Objectives of the consultancy The overall objective of the assignment is to help KHF design an alternative healthcare delivery system which is sustainable. the Kenya Healthcare Federation (KHF) is the apex organisation for private healthcare providers in Kenya. As a major stakeholder in the sector. critique and make proposals on the baseline package of health intended to be delivered and known as KEPH (Kenya Essential Package for Health).
Mr. 80. 82. 85. KHF proactively and constructively engages with the government and other stakeholders to deliver accessible. Under the Vision 2030 Master Plan several structural changes are envisaged to improve and expand the existing health sector in both public and private spheres to address the challenges. Scope of Work The study is to cover at least five Provincial and one district hospital within the province and two Health Centres. 86. KHF would like to carryout a baseline study to establish the status of healthcare delivery in both urban and rural areas.TIWI PR H C .TIWI Diani Health Centre Diani Health Centre Diani Health Centre Mewa Medical Centre Mewa Medical Centre Mewa Medical Centre Mewa Medical Centre
Msabweni Msabweni Msabweni Msabweni Msabweni Mombasa Mombasa Mombasa Mombasa
Annex 2: Terms of Reference 1. KHF is in the process of identifying a consultancy firm to carry the study. 81. quality and sustainable healthcare through enabling policies that maximise the contribution of private sector. 84. S. However the healthcare is currently faced with many challenges. Specific tasks will include. Mohammed Ali Ms Fatuma
Officer In change Nursing Officer RCO in Charge Nursing Officer Nursing Officer HAO CEO Chief Accountant Nursing Officer
PR H C . 83. This will help in designing an alternative approach for health service delivery including mobilisation of funds.79. comment.Chepkiwok Ms Anna Ms Mishi Mr. Background Under the auspices of Kenya Private Sector Alliance (KEPSA). affordable.
6. funding and facilities ownership. equipment. Expertise Required Demonstrated understanding of healthcare delivery systems. Experience in strategic planning.e) Collate. Outputs / Deliverables The main output of the assignment will be the baseline study report. It is expected that the assignment will be finalised within 90 calendar days from the date of start. the impact and implications on healthcare delivery c) Recommendations on the way forward
5. summarise and interpret the data f) Prepare findings and recommendations The selection of the provinces. The contents of the report will include: a) A baseline information indicating findings on physical facilities. districts and Health Centre should reflect a representative sample 4. human resource. Experience in carrying out baseline surveys. Timeframe The assignment should begin in the first half of November 2008. especially in the health sector. b) An analysis of the findings.
. The firm and/or nominated consultants must have carried out a similar baseline study and planning over the last five years. analyse.