ADVANCED COURSE

ASSESSMENT OF
COMPONENT: HEALTH
SYSTEMS STRENGTHENING
KIRICARE: A HEALTH
(HSS) FINANCING
MPH 2019-2020

GAKUU ESBON
STRENGTHENING
PROJECT
1.Mapping Context

Overview of the Health System

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 Leadership & gouvernance
Policy formulation & regulation of actors Interaction with the context
and processes Local, national, international
Other
determinants in
health

Organisation of health
Raise &
services
manage
resources First line health services, referral Results Goals
hospitals, specialised services
1. Human resources Universal access to Better health
Public & private, formal and informal quality health care
2. Financial & material providers
resources
Curative, preventive and promotional
3. Information care
4. Infrastructure &
equipment
Interaction with the population
promote community participation and service
accountability, …

Principles and values

Health care as a right, equity, solidarity, rationalisation & participation, autonomy & security, …

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Van Olmen et al, 2012
 Mapping Context: KIRINYAGA County
Total Area - 1,479 KM
Total Population- 610,411 (2019
census)
Population Density - 413/Km2
Urban: Rural Ratio - 16:84

ETHIOPIA Legend
UGANDA

SOMALIA

Public Hospitals
Private For Profit Hospitals
Faith Based Hospitals
INDIAN Primary Healthcare Facilities
TANZANIA OCEAN
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 ORGANIZATION OF COUNTY HEALTH SERVICES
NATIONAL REFERRAL HEALTH SERVICES

County Health System

LEVELS OWNERSHIP SERVICE COVERAGE

Referral services
• Comprehensive in-patient diagnostic, medical, surgical and
COUNTY REFERRAL HEALTH SERVICES: Government- 4 rehabilitative care;
County/Sub-county hospitals, including Faith Based- 2 • Basic & Specialized outpatient services; and
Faith-Based and Private run Hospitals Private - 4 • Facilitate, and manage referrals from lower levels, and further
Centralized: Permanent; Polyvalent referral.

Referral services • Disease prevention and health promotion services

PRIMARY HEALTH CARE SERVICES: All
Dispensaries, Health centers, Private
clinics & Maternity homes
Decentralized; Permanent; Polyvalent
• Basic outpatient diagnostic and medical services
Government- 59 • Inpatient services for emergency clients awaiting referral, clients for
Faith Based- 26 observation, and normal delivery services
Private - 66 • Facilitate referral of clients from communities, and to referral
facilities

Community Referral
• Basic Health promotion activities
Community Health Services
Community Units - 69 • Provide agreed health services e.g. deworming
Decentralized: Periodic; polyvalent
• Facilitate community diagnosis & referral.
 Key Indicators
Indicator Most Recent Value (Year)
Health Financing Total Health exp (THE)/capita (USD)(Kenya) 1 US$ 78.6 (2015/2016)
Revenue from user fees as a % of regional Government’s Total 4.8% (2018/2019)
Health Exp3
Government Health exp as % of THE1 37% (2015/2016)
Financial Protection Out-of-pocket exp as % of THE1 26.1% (2015/2016)
(Kenya) % of population in any form of health insurance2 23.9% (2018)
% of population incurring Catastrophic Health Expenditure1 4.9% (2015/2016)
Health Service % of population living within 5 km to a health care facility3 >90% (2018)
Availability (Kirinyaga) Skilled Birth attendance3 84.4 (2018)
Children under 1 fully immunized3 82 (2018)
Health Outcomes Maternal Mortality Rate (per 100,000 Livebirths) 3 89 (2018)
(Kirinyaga) Infant Mortality Rate (per 1,000 livebirths) 3 34 (2018)
Under 5 Mortality Rate (per 1,000 livebirths) 3 45 (2018)

Sources: 1 National Health Accounts, Kenya 2015/2016 2 Kenya Health Financing System Assessment, 2018 3 Kirinyaga Health Sector Annual Performance Report 2018/2019
SWOT analysis of County Health Services
Strengths
• Decentralised healthcare system
• Availability of policy guidelines and SOPs
• Reporting structures in place
• Existing infrastructure in most parts of the
County.
• Free services in public primary health
services
• Political good will in the provision of all
health services
• Highly qualified and skilled staff
Opportunities Weaknesses
• Need to create demand for preventive interventions • Relatively High Out-of-Pocket
offered at PHC facilities
Payment for health services
• Upgrading facilities from the lower levels to higher
level and potential for expansion of services • some health facilities do not offer
• Potential for expansion of services
the full range of services
• Potential for research partnerships and funding • High workload and unconducive
environment for patient centered
care in public facilities
• Inadequate budgetary allocation
• Weak regulation of private health
sector providers
• Weak referral system
Threats
• Emerging and re-emerging
diseases
• insufficiency of resources
needed to finance health care
• Inadequate health legal
framework for the County
• Changes in government policies
• Low uptake of medical cover
2.Overview of the HSS
Programme

Overview of the Health System

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 The Bill of Rights in the Kenyan constitution 2010 chapter four guarantees “every
person has the right to the highest attainable standard of health

 Revenue from user fees levied at public hospital only a small component of the total
health expenditure yet a major barrier to access to health services

 The level of out of pocket expenditure that is incurred by people accessing health care
in the county is high

 Close to 75% of the residents have no health insurance coverage of any form

 Fragmented health financing landscape with multiple funding sources

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 Problem: High out of pocket payments resulting in inequitable health service access and utilization
between different socio-economic groups and between poor

Short/Medium term changes
Policy Action Activities • Increased public investment in health
Remove user-fees in public • Mapping of indigents & • Abolition of user fees in public health facilities
hospitals and implement a County socioeconomic survey • Increased utilization across all service areas
led Pre-payment financing • Community • Gradual transition from OOP to pre-payment
mechanism (Kiricare) engagement schemes
• Rollout of prepayment
scheme.

Preconditions
• Community willing to participate
• Strong political support
Long-term changes/Impact
• Expanding access to equitable, affordable and
quality health care
• Financial Protection

Context
• Regional, National, International drives towards UHC
• Presence of pre-payment schemes (NHIF, CBHI schemes, Private Insurance)
• Mixed Health System
 A revenue generation and pooling mechanism aimed at raising revenues
for health services offered at public health facilities
 For a defined annual subscription per household the program aims to provide
access to affordable healthcare to >200,000 households eliminating user fees
 The regional government will supplement the household contributions to
ensure high quality health services are provided at all times in the health
facilities
 Target Population and scale: All Households within the administrative
boundaries of the regional government ~200,000 households
 Scope: The project is intended to provide a package of Quality essential
health care services in All county Public health facilities free of cost at the
point of care
 Implementation Duration: From 2019-2023
Stakeholder Expectations of Stakeholder Expectations from stakeholder Stakeholder
from the programme Impact
Client/Community • Quality health care • Cooperation High
• Compliance with service charter/benefit package • Compliance to rules and regulations, and prescribed
• Compassion, courtesy treatment
• Payment of bills where applicable

Government of • Implementation of health policies & standards • Budgetary support High

Kirinyaga County • Prudent resource management • Policy guidelines
• Professionalism, ethics and integrity • Equitable distribution of
• Good corporate governance • resources
• Participation in health planning and policy • Facilitation of bi-lateral and multi-lateral development
partnerships
• Involvement in policy formulation

Development • Good corporate governance • Mutually beneficial collaboration Moderate

partners • Feedback

Health • Administrative support • Enforce Professionalism High

workers/Professional • Compliance to standards • Provision of professional
• Compliance to statutory requirements • development
Bodies • Development of standards in health care
• Advisory role

Private Health sector • Participation in health planning and policy • Compliance to health standards Moderate

Religious groups/ • Availability services • Unbiased stand on Health Moderate

FBOs • Service provision without coercion or bias • Compliance to health standards
Stakeholder Expectations of Stakeholder Expectations from Stakeholder
from the Programme stakeholder Impact
Media • Access to accurate information • Accurate reporting Moderate
• Co-operation • Professionalism
• Professionalism • Enhanced programme visibility
• Respect patient rights

National • Implementation of health policies and standards • Budgetary support High

Government/Ministry of • Prudent resource management • Policy guidelines
• Professionalism, ethics and integrity • Timely response to county needs
Health • Good corporate governance • Enhance national referral system
• Disaster management • Equitable & timely distribution of resources
• Participation in health planning and policy • Facilitate bi-lateral and multi-lateral
• development partnerships
• Involvement in policy formulation

Politicians/Legislative • Good corporate governance • Mutually beneficial collaboration High

body • Feedback • Political good will
• Affordable and quality health services to the citizenry • Timely and favourable legislation on Health
• Consultation on policies related to health matters

Health Insurance • Quality healthcare • Timely settlements of claims High

Providers/Community • Honour contracts • Partnerships
Based HF schemes
Suppliers • Planned procurement and timely settlement of claims • Meet contractual obligations Moderate
• Integrity • Integrity
• Good Customer care relations • Customer care
• Competitive pricing
• Quality goods and services
• Timely delivery of goods and
 Stakeholder Analysis: Power/Interest towards Program goals
Key Players
Strong- Non-Supporters Strong- Supporters
Strong County
National/Ministry of
Health workers Health Government
Private Health
Care Providers
Community/Households
Private Insurance/CBHF Politicians/Legislature
schemes
Influence/Power

Passive Resistors -Monitor Passive-Keep Informed

Media
Religious
Suppliers Bodies Civil Society
NGOs

Weak/Low High
Interest of stakeholders
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 Conceptual
framework:
Develop the
framework,
define
envisaged Establishment of
management Relevant fund
structures and policy/bills & management
systems, share regulatory structures and
with key mechanisms-In systems-in Roll out-Not
partners.- Done Process Process done

Mapping of Technical Community Quarterly

indigents & review: With all education-In reviews, M&E
socioeconomic stakeholders, Process and continuous
survey-Done including improvement-
community
representatives
and civil society
organization-
Done
Results & Effects
Anticipated Positive Effects
Increased utilization of preventive & curative care
Anticipated Negative Results
Ineffective indigent identification
Quality of care barriers(HR and supplies shortages)
Imperfect information on entitlements
Adverse selection & Moral hazard
Informal fees
3.Coherence

Overview of the Health System

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 Strong Weak
• Clearly defined program evaluation plan • Some specialized services not included in the
benefits package.
• The objectives of the project are in line with the
organizational goals • Some organizational and Legal structures yet to be
Internal put in place
coherence • Leverage on existing public health infrastructure and
systems

• In line with the Presidential/National government “Big • Narrow focus on financing of public health system
4 Agenda”- Agenda 3-Affordable Health for all. in a mixed health system.

Alignment • A subset of the Regional Government’s Mountain Cities • Presence of other schemes could affect the
blueprint 2032-An ambitious long term transformative success of the program e.g Community Health
with plan. Financing schemes
environment • Mechanism for identification of indigents implemented
• Political goodwill and devolved governance to health
can be an asset.

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