Is Kenya’s health system ready for devolved governance?

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34-63% of counties have maternal health tracer drugs but 18-39% of child health tracer drugs available
Large disparities in the availability of first line HIV drugs (0-50%)
Kisumu, Kisii, Vihiga, and Siaya consistently top third in drug availability
Transzoia, E-Marakwet, Nandi, Nyeri & T.River bottom
11 maternal health tracer drugs
11 child health tracer drugs
First-line drugs for HIV
ACT, first line treatment for malaria
4FDC, intensive treatment for tuberculosis
Metformin, preferred OGLA treatment for diabetes

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Is Kenya’s health system ready for devolved governance?

  1. 1. Is Kenya’s health system ready for devolved governance? Aaron Mulaki Health Systems/Public Administration Advisor June 20, 2014
  2. 2. Context
  3. 3.  Kenya recently celebrated its first birthday in a devolved system of governance following the March, 2012 elections under 2010 constitution  Devolution in Kenya not new. False start in 1963 under majimbo followed by failures in other decentralization reforms  Devolution is pursued for technical, political, and financial reasons  In Kenya devolution of power seeks to correct historical injustices associated with centralized governance  Kenya’s devolution framework considered complex in scale and magnitude  New constitution progressive in bill of rights Why devolve?
  4. 4.  Principles-Democracy, separation of power, reliable resources, gender (Art 175, CoK)  Objectives (Art 174)  Promoting democratic and accountable exercise of power  Fostering national unity by recognizing diversity  Enable self governance to the people  Enhance participation of the people in the exercise of the powers and the state making decisions for them  Recognize the right of communities to manage their own affairs and to further their development  Promote social and economic development and the provision of proximate, easily accessible services  Ensure equitable sharing of national and local resources  Facilitate the decentralization of state organs, their functions and services  Enhance checks and balances and separation of power Kenya’s devolution framework
  5. 5.  Numerous reforms implemented with mixed results (e.g DHMTs)  Devolving health will improve efficiency, stimulate innovation, improve access and equity, and promote accountability and transparency  Schedule IV assigns policy, national referral facilities, capacity building to national government and service delivery to counties  Devolving health has had its fair share of challenges  Success on uptake of health function by counties is largely dependent on health system preparedness Decentralization of health not new!
  6. 6. Assessing county health system readiness Overview of Methodology
  7. 7.  Examined variations in county revenue per capita  Assessed availability of health facilities  Assessment of 16 county level health input indicators based on the WHO building blocks under four categories;  Physical infrastructure and equipment; human resources for health; drug availability, organization of service delivery and governance  Data sources included:  SARAM-Kenya Service Availability and Readiness Assessment Mapping (SARAM), a census involving all health facilities in the country and management units  Pets-Plus- a combination of Public Expenditure Tracking Survey and a Service Delivery Indicator (SDI) survey that assesses overall service delivery performance of 294 public and nonprofit private health facilities and 1,859 health providers in Kenya How was county health system readiness analyzed?
  8. 8. Results
  9. 9. Availability of health facilities There is inequality in health facility distribution across 47 counties Counties must make sure that their clients spend little time accessing a facility, and facilities must be able to handle as many case loads • Half of counties have fewer than 2 health facilities per 10,000 people and 4.2 facilities per 100 square kilometers • Mombasa and Nairobi have 134 and 124 per 100 sq kms, but have far fewer facilities per 10,000 (2.9 and 2,4 respectively) • Bungoma and Busia have fewest facilities per 10,000 people but more facilities per 100 sq kilometers • Kilifi, Mandera,Turkana, Wajir, Narok and Bomet have low number of facilities per 10,000 and low number of facilities per 100 sq kms
  10. 10. Performance on infrastructure and equipment poor 1. Percentage of primary care centers with an ante-natal(ANC) ward • Huge variations (8-85%) 2. Number of operating theatres per hospital • 0.09 to 2.33 3. Number of ambulances per hospital • 0.06 to 3.636 4. Number of KEPI refrigerators per maternal and child health unit • 1.13 to 3.87 5. Number of CD4 machines per facility with laboratories • 0 to 0.58 • Samburu is the only county that is in the top third for at least 4/5 indicators • Isiolo, Narok, Kericho, Elgeyo Marakwet and Bungoma are the only counties that do not fall in the bottom third in any of the indicators • Kirinyaga,Wajir, Kajiado consistently in the bottom third of all counties across all the indicators Equipment/Infrastructure Availability
  11. 11. Human Resources for Health  Doctors per 10,000 people in the 47 counties ranges from (0) Mandera to (2) Nairobi benchmark is 3(MOH,2013b)  Higher densities for nurses between 0.9 per 10,000 (Mandera) to 11.8 per 10,000 (Isiolo)  Only 4 counties meet Kenya’s benchmark of 8.7 per 10,000. Staff absenteeism • W.Pokot, Makueni have lowest rates < 20% • Nyamira, Siaya, Transzoia, Uasin Gishu >40% Diagnostic Capacity • Makueni, Nairobi, Mombasa >80% • Homabay, Kitui, Uasin Gishu, Kilifi Quantities Quality
  12. 12. Availability of drugs • 34-63% of counties have maternal health tracer drugs but 18-39% of child health tracer drugs available • Large disparities in the availability of first line HIV drugs (0-50%) • Kisumu, Kisii, Vihiga, and Siaya consistently top third in drug availability • Transzoia, E-Marakwet, Nandi, Nyeri & T.River bottom 1. 11 maternal health tracer drugs 2. 11 child health tracer drugs 3. First-line drugs for HIV 4. ACT, first line treatment for malaria 5. 4FDC, intensive treatment for tuberculosis 6. Metformin, preferred OGLA treatment for diabetes Drug types Average availability
  13. 13.  Revenue per capita (RPC) ranges significantly by county. Mandera has 6 times the per capita of Nairobi  RPC sometimes corresponds to counties’ performance across the 16 indicators e.g Nairobi has the least RPC and is in the bottom third of counties for 9/16 indicators.  Machakos, Narok, Nakuru, Kericho, Siaya, Kakamega & Makueni with below average RPC preform better than other counties  Counties with above average RPC that are in the bottom third for at least 8/16 indicators  RPC not necessarily linked to county health system readiness County readiness and Revenue
  14. 14. Conclusion and Recommendations 1. Focus on relatively low-performing counties 2. Target weak areas across all counties 3. Provide counties with norms and standards for benchmarking • There is great variability in county health system readiness • About nine counties preform consistently poorly-bottom third across the 16 indicators • Counties that performed relatively well across the indicators may still have inadequate inputs
  15. 15. www.healthpolicyproject.com Thank You! The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with CEDPA (CEDPA is now a part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA).

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