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

1. Is Kenya’s health
system ready for
devolved
governance?
Aaron Mulaki
Health Systems/Public
Administration Advisor
June 20, 2014

2. Context

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.  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.  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. Assessing county health system
readiness
Overview of Methodology

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. Results

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. 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. 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. 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.  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. 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. 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).