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HSDPF Dr. Elizabeth Ogaja Presentation, ECM Health, Kisuu County-HRH and UHC - Health Sector Development Partner Forum


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HSDPF Dr. Elizabeth Ogaja Presentation, ECM Health, Kisuu County-HRH and UHC - Health Sector Development Partner Forum

  1. 1. Human Resource in Health and UHC Kisumu County Health Sector, Kenya Dr. Elizabeth Ogaja Minister of Health Services & Promotion of Health Investments, Kisumu County, Kenya 9th Oct 2015 Health Sector Development Partners Stakeholders Forum
  2. 2. OUTLINE 1. Health Reform in Kenya 2. Health in Kisumu County 3. Policies and Strategies for HRH 4. Opportunities and Challenges 5. Conclusion
  3. 3. HEALTH REFORM IN KENYA Health Reform in Kenya
  4. 4. Health Policy and Constitution Vision 2030 •To create a globally competitive and prosperous nation with a high quality of life by 2030 Kenya Constitution 2010 •Introduces a devolved system of government which would enhance access to quality services by all Kenyans Kenya Health Policy 2012 – 2030 •Seeks to make the realization of the right to health by all Kenyans a reality as defined under Art 43. of the Constitution
  5. 5. HEALTH SYSTEMS – ref. WHO 1. Human Resource for Health 2. Service Delivery 3. Health care financing 4. Infrastructure 5. Essential Health Products and Technologies 6. Health Management Information System 7. Leadership Management and Governance
  6. 6. Patient Focused Healthcare HEALTH FACILITY Prevention Investigations Diagnostics; Treatment Equipment Medicines MedicalSuppliesConstitution of Kenya: Article 43. (1) (a) Every person has the right—to the highest attainable standard of health… Community Strategy = Community Health Services Community Strategy = Community Health Services
  7. 7. Devolution of Health Sector, 2013 • National Ministry of Health Steers implementation of national policies and development of standards for service delivery CURRENT STATUS • 47 new County Ministries of Health Administrative authorities • Fiscal authorities in health service delivery
  8. 8. HEALTH IN KISUMU COUNTY Health Reform in Kenya
  9. 9. Kisumu County Population Over 1 million (national 43 million) Poverty rate 47% (national 45.9%)
  10. 10. HRH Training Centres in Kisumu County Maseno University •School of Medicine Uzima Medical College •School of Medicine and School of Nursing Great Lakes University Kenya University •School of Community Health •School of Public Health Kisumu Medical Training Colleges (3 campuses) •Annual output of 300 trained health workers •Diploma in Community Health Nursing, Clinical Medicine, Medical Laboratory Sciences
  11. 11. Some thoughts on HRM Policy • National Policy on HRH has been finalized and launched – how are we as counties undertaking the customization and implementation? • Must move away from 1 person HF management structures • Ideally a primary health facility should have a minimum of 12-14 staff depending on work load: 1. Clinical Officer 2. Nursing Officer 3. Pharm. Tech 4. Lab Tech 5. Public Health Officer 6. Admin. Officer 7. Nutritionist Need at least 2 per cadre – more if the workload demands Need to plan for the application of the WHO Workload Indicator of staffing needs methodologies
  12. 12. Poor Health Coverage
  13. 13. Health Indicators Kisumu County Health Sector (2013) , (2014), (2014) Indicators Kisumu County Kenya Germany Life expectancy at birth in years 61 61 81 Under-5 mortality rate per 1000 live births 105 73 4 Maternal mortality ratio per 100,000 live births 600 488 7 Births attended by skilled health personnel 60% 43.8% 98.6% Malaria prevalence 37% n.a. n.a. HIV adult prevalence 17% 6.2% 0.1%
  14. 14. Possible obstacles to UHC Financial, Geographic and Therapeutic Barriers •Little risk-pooling •High out of pocket payments •Insufficient quantity and quality of health care services •Geographically hard to reach •Mismanagement of resources •Demotivated staff •Understaffed health facilities Chuma & Okungu (2011), Flessa (2013), World Bank (2014)
  15. 15. HRH Statistics Cadre Per 100,000 Kisumu, 2012 (MOH, 2013) Kenya, 2012 (MOH, 2013) WHO minimum recommendation Nurses 73 (54% of WHO recommendation) 49 (36% of WHO recommendation) 135 Doctors 10 (28% of WHO recommendation) 7 (19% of WHO recommendation 36 Laboratory Technicians 6 7 Pharmacy Technicians 1 1 Public Health Officers 10 4 Kenya Ministry of Health (2013), Kiambati et al. (2013
  16. 16. Kisumu County HRH Kisumu County HRH Total Comments Salaries covered by County Government 1,600 (84%) • All cadres, including administration • 16% of total county health budget • One third employed at regional referral hospital Salaries covered by partners 300 (16%) • Clinical and medical health care & records staff. • Partners funded by PEPFAR • More than ½ of the contracts will end in 2016; renewal only if donor funding continues. • Distributed throughout all 6 sub-counties and at all health facility tier levels. Total 1,900 (100%)
  17. 17. Health Financing in Kisumu Types Comments County Government • 33% of total county government annual budget. • One third for regional referral hospital. • Includes free public Primary Health Care services. Free maternity care services Endorsed by the government in 2013 to sink high MMR. Fee for services At 3rd and 4th tier level public health facilities Out-of-pocket payments Nation-wide: 77% (World Bank, 2014) Partner support • 16% of county HRH. • Capacity building and commodities of health facilities (these are often not reported to county)
  18. 18. Health Financing in Kisumu (cont.) Types Comments National Hospital Health Insurance (NHIF) Primary provider for health insurance in Kenya. Covers inpatient care. Compulsory for employed personnel. Low coverage. Community-Based Health Insurance (CBHI) STIPA (NGO) 4,700 beneficiaries in Kisumu County. Targets low-income and informal sector. Other NGOs providing CBHI include KMET and Changa Muka. Output-based Aid Vouchers for Safe Motherhood Services. Target: economic- disadvantaged women. KfW and BMZ funded Social Franchising Insurance (premium payments) for outpatient, maternity and referral services in private sector. Pilot phase in 2 counties, including Kisumu. Target: 6,200 low-income earners. KMET (NGO) and PharmAccess. Funded by Dutch Government.
  19. 19. POLICIES AND STRATERGY /HRH Health Reform in Kenya
  20. 20. Framework for policy direction
  21. 21. Kenya Health Policy 2012-30
  22. 22. Kisumu County Strategy Plan 2013-2017 Orientation Area Intervention Area Milestones Health workforce Recruitment and secondment of staff from national government Develop norms and standards of staffing Yearly recruitment of staff CHW allowances 2544 CHWs (approx. 1 million USD p.a.) Personnel emoluments Review salaries and allowances upwards Pre-service training Initiate sponsorships/scholarships with 5- year bonding In-service training Enrol staff on trainings, CPD Staff motivation Conduct staff satisfaction survey, Operational Research
  23. 23. OPPORTUNTIES AND CHALLENGES Health Reform in Kenya
  24. 24. Opportunities Kenya’s Health Policy 2012-30 •Emphasises every Kenyan’s right to health •HRH is identified as policy orientation Decentralised County Health Sector •Potential to fully utilize resources efficiently and effectively Kisumu Strategic Plan •Recognizes the need of attracting, obtaining and maintaining HRC •Determination to invest in CHWs and strengthen PHC PPP -Universities contribute to research in health -Partners are taking lead in UHC initiatives (e.g. MSH launching UHC program)
  25. 25. Governance of Health Sector at the Policy Level • National Ministry of Health: – Department for HRH Management & Development • County Governments – Council of Governors • Committee on Human Resources • Committee on Health and Biotechnology – Council of County Health Ministers • HRH • EHPT • Health care Financing • Inter-county relations • ICT in Health and Health Informatics • PPP in Health • Health Research and Quality Assurance – Inter-county HRH Forum
  26. 26. INTRA-COUNTY GOVERNANCE STRUCTURES • County Executive for Health Services • County Health Management Coordinating Committee • Sub-county Health Management Teams • Ward Health Managent Teams? • Facility Health Mangement Teams
  27. 27. COUNTY HEALTH MANAGEMENT COORDINATING TEAMS • Will depend on the way the Health department is structured in each County • Must reflect the functions as tranferred by: – The Constitution (including Sch 4 as well as the Transition Authority Gazette Notice no. 139) • Governance structure – developed with assistance of organizational reform experts
  28. 28. COUNTY HEALTH MANAGEMENT COORDINATING COMITTEE • CEC • CHIEF OFFICERS • DIRECTORS – Preventive Promotive Healthcare – Community Health Services – Referral Health Services – Curative Health Services • MEDICAL SUPERINTENDANTS/ FACILITY MANAGERS – Service Delivery Teams • Medicines and Therapeutics Committee • Nursing Services • Surgical Services • Paediatric Services • Maternal Health Services • Adolescent Health Serivces • Patient Support Services
  29. 29. Structures for County Government NEED TO GET IT RIGHT FROM THE BEGINNING
  30. 30. .Pass and enact legislation, .Vet and approve appointments of county public offices, .Approve budget and expenditure of county government County -Sub-county -Ward -City -Municipality Enabling Legislation Regulations & Enforceme nt Oversight Policy formulatio n -Harmonization of different levels of Staff -Skills & Competencies -Deployment& secondment -Terms & conditions of service -Remuneration -HR Audit, Head count -National Capacity Building Programme -Capacity Building Transformation Initiative -Skills, Audit -Learning -Professional competencies for Government HR, Financial Management -Procurement -Performance Management -Strategic Planning, ICT -Asset Management -Budget, ISD -Risk Management County Offices -Equipment -County Assembly chambers; -Vehicles, etc. -Accommodat ion -Assets
  31. 31. COUNTY ASSEMBLY Pass and enact legislation, Vet and approve appointments of county public offices, Approve budget and expenditure of county government
  32. 32. STRUCTURE County Sub-county Ward Village (in the Constitution – yet to be formalized in some counties) City (some counties) Municipality
  33. 33. POLICY, LEGAL & REGULATORY ENVIRONMENT Enabling Legislation Regulations& Enforcement Oversight Policy formulation
  34. 34. STAFFING Harmonization of different levels of Staff Skills & Competencies Deployment& secondment Terms & conditions of service Remuneration HR Audit, Head count
  35. 35. CAPACITY BUILDING National Capacity Building Programme Capacity Building Transformation Initiative Skills, Audit Learning Professional competencies for Government
  36. 36. SYSTEMS, PROCESSES AND PROCEDURES HR, Financial Management Procurement Performance Management Strategic Planning, ICT Asset Management Budget, ISD Risk Management
  37. 37. INFRASTRUCTURE County Offices Equipment County Assembly chambers; Vehicles, etc. Accommodation Assets
  39. 39. The county programs based on fourth schedule of the Constitution of Kenya 2010 (Continued…) Sam ple
  41. 41. THERE SHALL BE ESTABLISHED AT THE LEVEL OF EACH SUB-COUNTY THE OFFICE OF THE SUB-COUNTY ADMINISTRATOR. Subject to subsection (3) of the County Government Act, the functions and provision of services of each county government shall be decentralized to— •The urban areas and cities within the county established in accordance with the Urban Areas and Cities Act (No. 13 of 2011); •The sub-counties equivalent to the constituencies within the county established under Article 89 of the Constitution; •The Wards within the county established under Article 89 of the Constitution and section 26; and •Such number of village units in each county as may be determined by the county assembly of the respective county and such other or further units as a county government may determine.
  42. 42. IF THE CONSTITUENCY OR PART OF A CONSTITUENCY FALLS UNDER URBAN AREAS OR CITIES, THAT CONSTITUENCY OR PART OF THE CONSTITUENCY, SHALL BE CONSIDERED AS FALLING UNDER SUBSECTION (1)(A) OF THE COUNTY GOVERNMENT ACT. The Urban Areas and Cities Act, provides for classification, governance and management of urban areas and cities to provide for the criteria of establishing urban areas to provide for principle of governance and participation of residents and for connected purposes. An urban area can be classified as a city under this Act if the urban area satisfies the criteria set in Section 5 of the Urban Areas and Cities Act. Under Section 27 of the Urban Areas and Cities Act, a city county shall be governed and managed in the same manner as a county government.
  44. 44. shall, in the case of a town, be performed by a Town committee appointed by the county governor and approved by the county assembly.
  46. 46. HUMAN RESOURCE MANAGEMENT • Gauge the actual numbers scientifically – WHO Methodology – Work Indicator of Staffing Needs – Facility-based calculation – Based on workload and available work days per cadre – Facility numbers – aggregate to sub-county and county level – Human resource budget – calculate based on current schemes of services (including approved allowances) – Capacity Building on the use of the WISN methodology is required
  47. 47. CHALLENGES for HRH •Critical shortages in HRH nation and countywide – address this by using a professional method of estimating numbers •Regeneration of Health Workforce: Outflow higher than inflow – need to professionalize human resources management with highly qualified HRM and HRD managers embedded within the County Ministries of Health •Discontinuation of partner support will have critical outcome on health coverage (16% of HRH supported by partners) – The Government has no option but to rationalize and invest in HRH for UHC •Young leaders in health sector with little experience in management: •Addressed by proper preparation for service: –Orientation –Management Training –Professional Development –Mentorship •One third of Kisumu County’s health budget is allocated to regional referral hospital. This creates bottlenecks in Primary Health Care and HRH regeneration
  48. 48. CHALLENGES FOR HRH National Government • Are the HRH at the NG properly capacitated for their role as policy formulators: – How many formally trained in policy formulation and analysis – How many formally trained in M & E especially for policy development and strategic planning – How many formally trained in the development of standards of health service delivery County Government Primary responsibility is implementing health policies, strategies and guidelines – Training needs assessment must be done – to cater for the role given by the Constitution – Require training in programme based budgetting, strategic planning – Training in Health Systems Management – Management training for coordination of health services – Communication strategy
  49. 49. CONCLUSION Health Reform in Kenya
  50. 50. Towards UHC and sustainable HRH National MOH •To develop comprehensive evidence-based policy framework to address critical shortage of HRH (e.g. Innovated Human Resource Solutions/ IHRS) •To develop Service Charters (SOPs, Quality Management, Benchmarks) •To provide affected counties with sufficient conditional grand for regional referral hospitals County MOHs •To take an active role in coordination of PPP towards UHC •To strengthen resource mobilisation •To invest in Primary Health Care and in HRH •To build capacity of health managers so that they may plan resources effectively, efficiently and equitably
  51. 51. TOWARDS UHC AND SUSTAINABLE HRH • Investment pillars for UHC – Human Resources for Health – Infrastructure – Essential Health Products and Technologies – Health Financing
  52. 52. Thank you for your attention!
  53. 53. References Chuma & Okungu (2012) ‘Viewing the Kenyan health system through an equity lens: implications for universal coverage’, International Journal for Equity in Health. Dunne (2013) ‘Tackling the Challenges of Human Resources for Health (HRC) Strengthening in Kenya’, Global Health Fellows . Health Rights Advocacy Forum/ HERAF (20120 ‘The health service commission – They Kenya Ministry of Health (2013) Kisumu County Health at a glance ( Kfw (2012) ‘Vouchers for reproductive health care services in Kenya and Uganda’. Kiambati et al. (2013) ‘Understanding the labour market of human resources for health in Kenya’, WHO Working Paper. Koon (2013) ‘The road to universal health coverage in Kenya’, London School of Hygiene and Tropical Medicine. KPMG (2013) ‘Devolution of Healthcare Services in Kenya’/ Lessons learnt from other countries’. Flessa (2013) ‘Kenya’s Road to Universal Health Coverage –The Roles of the Public and Private Sector’, Universitaet Greifswald WHO (2014 ) Out-of-pocket health expenditure data ( WHO (2010) Global Atlas of Health Work Force (