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082007 kenyamohper06lastestjan07

  1. 1. Republic of Kenya Ministry of Health Public Expenditure Review 2007 Printed on: 14 November 2013
  2. 2. Contents Contents..............................................................................................................................i Abbreviations......................................................................................................................i 1 Background......................................................................................................................1 2 Government Spending on Health through the MoH...................................................25 Table 2.2.7 Total reported revenue collection by province and financial year (KSh million)..............................................................................................................................39 3 Review of Projects/Programs related to the Ministry...................................................39 Table 3.3: Summary of programmes, goals, outputs and indicators.............................42 4 Pending Bills..................................................................................................................51 5 Analysis of Ministry outputs and corresponding performance indicators..................53 6 Public Expenditure Management (PEM).....................................................................57 7 Human Resources Development and Capacity Building.............................................60 8 Implementation of Recommendations of the 2006 PER..............................................65 9 Challenges and Constraints.........................................................................................67 10 Conclusions and Key Recommendations...................................................................68 11 Annexes........................................................................................................................71 12 References....................................................................................................................73 Abbreviations Description AIDS Acquired Immune Deficiency Syndrome CBS Central Bureau of Statistics GDP Gross Domestic Product HIV Human Immunodeficiency Virus MDG Millennium Development Goals MoH Ministry of Health i
  3. 3. NHA National Health Accounts NHSSP National Health Sector Strategic Plan PER Public Expenditure Review PRS Poverty Reduction Strategy MoF Ministry of Finance DHMTs District Health management Teams PHMTs Provincial Health management Teams FBOs PRSP SARS HLA Faith Based Organizations Poverty Reduction Strategy Paper Severe Acute Respiratory Syndrome Human leukocyte Antigen ii
  4. 4. 1 1.1 Background Overall objective of the PER The overall objective of the PER 2007 is achieving targeted results through efficient public spending. 1.2 Objectives of the Ministry’s PER The Public Expenditure Review (PER) for health is considered an integral component of the budgeting process and as part of overall economic recovery strategy yet be consistent with the general macroeconomic framework. The overall objective of the review is to assess the extent of public expenditure on health. The specific objectives are as follows:  Present the Government of Kenya's (GoK) policies and objectives in the health sector, and the broad programmes and activities to achieve these over the next three years, annually;  To examine the distribution of public health expenditure by sub vote, and economic categories;  To assess the absorptive capacity of resource in the health sector,  To assess the compliance of financial discipline in the health sector;  Assess the extent to which the expenditures are aligned to policies and objectives in the health sector;  Review the effectiveness of expenditures;  Identify budget related constraints and resource-use;  Set out the broad annual financing requirements to implement planned activities using existing facilities and capacity, but removing short-term constraints while working to eliminate long-term constraints; and  Establish priorities in recognition that there are constraints of financial, technical and physical nature that have to be addressed if the country is to improve its health outcomes.  The efficiency of expenditures as measured by results achieved and their coherence with the sector strategy targets;  The equity of expenditures measured by their contribution to promote more equal distribution of resources;  Budgetary procedures and institutional arrangements. /1
  5. 5. 1.3 Health Status Indicators Kenya’s epidemiological and demographic landscape has not changes significantly as the disease pattern is still dominated by communicable diseases. However, lower total fertility rates have been witnessed. Since 1993, the number of children born per woman has declined from 6.7 1 in 1989 to 4.9 in 2003, KDHS (2003), and the infant mortality rate increased from 73 in 1998 to 77 live births by 2004. Population growth is high by world standards, but has been declining, now estimated at 1.8% per year (Central Bureau of Statistics, 2002) while the contraceptive prevalence rate marginally increased to 41% by 2003 among married women of reproductive age. Communicable diseases (infectious and parasitic diseases) such as malaria and tuberculosis continue to be prevalent. In addition, diarrhoea diseases, acute respiratory infections, skin diseases and complications of pregnancy are also very commonly seen. Child malnutrition is reflected in the recent finding (2003) that 20% of children were found to be moderately underweight for their age. On a favourable note, though HIV is still a serious problem its prevalence seems to be declining - now estimated at 6.1%? On the whole, there are wide regional disparities in health status indicators, and significant differences between urban and rural areas [see KDHS]. 1.4 The Health Services Delivery System The Ministry of Public Health (MoH) operates a four-tiered system 2 of health care facilities, delivering primary health care in dispensaries and health centres and (Levels 1 and 2) at the locational levels and secondary care at district and provincial hospitals (level 4 and 5), and tertiary care at national referral hospitals (Kenyatta and Moi) (level 6). However, the system has been characterized by a number of serious problems— many of which are addressed by the NHSSP II and briefly and discussed below. Limited institutional capacity and lack of financing The NHSSP II 2005 – 2010 addresses the problems arising from the weak institutional framework of the health sector, which comprises an under equipped and understaffed public health system and a rapidly growing (and largely unregulated) private sector. 1 2 Excludes the northern part of the country See the NHSSP II /2
  6. 6. In the past, the MoH has been overly centralized and unable to coordinate effectively its services. The core functions of the MoH are regulation, policy analysis and planning, evaluation and monitoring, and management of service delivery. The centre (Ministry of Health) largely controls the disbursement systems, while the District Medical officers of Health (DMOH) handles expenditures for the lower levels, sometimes irrespective of their priorities. 3 There is, however, decentralization initiative, to devolved authority for spending to rural health facilities (health centres and dispensaries); one effect of this decision will be to minimize opportunities for misallocation of resources as funds will be disbursed directly to them. They in turn will be held accountable for the expenditures incurred. Efficiency in the allocation of scarce funds: Allocation of funds is highly centralized, and has been directed to health facilities (hospitals, health centres and dispensaries) using resource allocation criteria especially on operations and maintenance. Overall, the MoH spent about KSh 23 billion ( KSh 19.8 billion on recurrent; KSh 3.2 billion on Development) on health in 2005/06. Lack of accessibility to facilities for most of the population was due to limited geographic coverage compounded to some extent by lack of access due to need for cash payments required to receive care: the indirect costs of transportation to facilities are added to the direct costs of paying the fees required for consultations and/or prescription drugs. 1.5 Linkage between ERS, NHSSPII Acknowledging many of the challenges faced by the health sector, the NHSSP II is an integral part of ERS, from which it is derived identifies several key components of the ERS policy as it relates to the health sector include:  Revisiting the financing of the sector: Introduce the National Social Health Insurance Fund (NSHIF) in a phased approach to eventually achieve universal coverage of free health care for the Kenyan population.  Focusing on investments to benefit the poor: Reallocate resources towards promotive, preventive and basic health services and enlist additional capacity through partnership arrangements. 3 See financial flow to health facilities. /3
  7. 7.  Increasing cross-sector cooperation: For MOH, strengthen ties and collaboration across sectors in the areas of agriculture, water and sanitation, education, roads, culture and social services, etc.  Increasing efficiency and effectiveness: For MOH, adopt a programmatic approach with all partners involved (sector wide) leading to a jointly agreed strategic plan, financing mechanisms, M&E framework, and procedures for annual sector programme review, together with a jointly agreed medium-term expenditure framework (MTEF).  Increasing GOK funding: Increase health sector funding from the current level of 5.6% of total public expenditure to 12% by the end of the ERS period. The ERS identifies key policy actions necessary to spur the recovery of the Kenyan economy and is based on four pillars reflecting the overall goals of our society. Firstly, the Government will seek to maintain revenues at above 21 per cent of GDP to enable the bulk of Government expenditures to be financed from tax revenues. Secondly, and more fundamental pillar is strengthening of institutions of governance. The third pillar is rehabilitation and expansion of physical infrastructure and lastly, the fourth pillar is investment in the human capital of the poor. Addressing health sector, in particular, the ERS identifies crucial efforts like meeting the health challenge through the establishment of a comprehensive National Social Health Insurance Fund (NSHIF) which will provide both in patient and out patient services to all Kenyans; continuing the battle against the HIV/AIDS pandemic by putting in place an integrated approach to prevention, increasing community involvement and ensuring the special health care needs of the infected are met, rehabilitation of existing health facilities; and overhauling the system of procurement and distribution of drugs for public health facilities in order to reduce cost of drugs and make them affordable and also to rationalize the distribution system to ensure that drugs are supplied to areas where most needed. The ERS notes that provision of health services should recognize the people’s needs and lifestyle. In this regard, the existing health facilities have to be made more accessible, properly stocked, staffed and improved in terms of infrastructure and equipment relevant to the social and physical environment. In this regard, Government efforts will be directed at:  Strengthening community-based health care programmes, and promoting mobile outreach clinics for remote areas; /4
  8. 8.  Ensuring that drugs and equipment meant for health facilities reach the intended destinations;  Intensifying immunization of vulnerable children and other members of the pastoralist community and strengthening district capacity to detect and contain epidemics; and  Providing public health education to communities for preventive and promotive health care. 1.6 NHSSP II - Key principles of AOP2 In keeping with the five broad policy objectives of the second National Health Sector Strategic Plan for 2005–2010, AOP 2 was developed with four main principles as guides. These are:  Norms and standards for the various service delivery levels guided the development of the implementation plan in the area of human resources, infrastructure and commodities.  The move towards SWAp helped to strengthen synergies among the various stakeholders contributing to the realization of the health targets. For the first, time the outputs of major FBOs/NGOs in the health sector have been included in the annual operational plan.  The results-based management system introduced in AOP 1 highlighted the need to define specified outputs for the various levels of health care to ensure that performance can be monitored during implementation. 1.7 Strategic issues and policies of the ministry 1.7.1 Flow of funds to rural health facilities The Government introduced the District Focus for Rural Development Strategy in 1984, to act as a catalyst for harnessing and mobilising resources for maximum utilisation in the development of the rural areas where 80 percent of population lives. Under this Strategy accounting services were centralised within the District Treasuries to enable them serve all the Authority to Incur Expenditure holders. The District Treasury also became responsible for financial management of all Government funds in the districts. The Strategy though a noble one, faced various challenges including:  Inadequate cash liquidity at District Treasuries to support district activities; /5
  9. 9.  Inadequate participation of communities and lower level administrative structures in the planning processes;  Lack of systems to ensure funds flow to the spending units. Although Treasury has taken several measures to eliminate these challenges, more reforms are required to ensure that funds flow to the spending units, are utilised for intended purposes and communities get value for the money. The 2005 public Expenditures Tracking Survey shows that 45% of funds and commodities earmarked for rural health facilities do not reach these units. The inability of the rural health facilities to access funds on time has hindered their operations and almost brought to a stand still the implementation of public health activities. This, among others factors, may be the cause of deterioration of health status in the districts. The Government has increased the allocations to the health sector to 8.4% of the total Government expenditure and this is expected to increase to 9.6% by 2008/9. These additional resources are intended to upgrade health infrastructure, procure medical commodities and support implementation of community strategy in line with the Ministry’s Second National Health Sector Strategic Plan (2005-2010). The implementation of the community strategy and focusing attention to the lower level facilities will require modification of the financing arrangements for faster resource flow. However any modification must be within the existing Government financial regulations and procedures. Given that the Ministry is looking forward to a Sector Wide approach (SWAp), as a coordination framework for the provision of health care services in the country, the flow of resources to health facilities and accountability is critical in achieving objectives and vision of the Second National Health Sector Strategic Plan. The rural health facilities provide the frontline avenue in the delivery of health services in the country. There is need to ensure that financial resources are availed to make these services effective. The MoH has, therefore, developed a Paper therefore that defines the Ministry’s position of disbursing funds to health facilities with an aim to create a robust financial system to facilitate:  Timely disbursement of funds,  Production of timely financial returns; and  Timely and accurate accounting for resources in the sector. /6
  10. 10. The Paper highlights crucial areas like: risk management, facility management structures, minimum staff requirements, resource allocation criteria, and mechanisms of the flow and accountability of funds, and lastly, monitoring and evaluation. 1.7.2 Guidelines to financial flow to health centres and dispensaries In order to facilitate the implementation of the Position Paper on the flow of funds to the health centres and dispensaries, comprehensive Guidelines have been developed, in recognition of the importance of empowering the rural health facilities management to make decisions on the use of the resources made available to them. As expected, the local community will enjoy good access to services, with ultimate improvement in health status. The Guidelines aim at contributing to the strengthening of rural health management capacity, with emphasis on financial management. The starting point in service delivery is to prepare work plans. The facility work plan shows how services are organized as well as how resources (such as finances and personnel) are combined to render the service. Important components covered by the Guidelines include: resource management, planning health facility activities, operating financial management systems, procurement of goods and services, and documentation of accounting records. Emphasise is given of the development of work plans and approved by the management committees as a starting point in financial management. It will be on the basis of the plans that financial resources will be released to the facilities. 1.7.3 Procurement position paper The Government is committed to the attainment of the millennium development goals (MDG) as well as the targets set in the Economic Recovery Strategy for Employment and Wealth Creation (ERSWC). Revitalising the health sector in order to improve service delivery and ensure community participation as well as enhancing cooperation with all stakeholders in the sector is therefore being undertaken. A five-year Second National Health Sector Strategic Plan 2005-10 whose goal is to reserve trends in health outcomes has been developed with an orientation on output and performance. This is in line with the Government reforms that are intended to institutionalise results based management approach in the public service. The ministry has initiated processes aimed at implementing the Plan through the Sector Wide Approach (SWAp). /7
  11. 11. The position paper which outlines procurement improvement plan is part of the preparation of the four year Joint Programme of Work and Funding, 2006-2010, and provides critical analysis of the procurement capacities, competences as well roles and functions of the procurement entities of the various levels within the Ministry of Health. Public procurement is broadly defined as the purchasing, hiring or obtaining by any other contractual means of goods, construction works and services by the public sector. The importance of government procurement from a development perspective is self-evident, as the purchase of goods and services accounts for KSh 8 billion (30% of MOH allocation) The need to enhance transparency in public procurement cannot be over-emphasized within the framework of the Programme of Work. This position paper addresses the following issues and proposes the possible interventions in order to facilitate a more efficient and effective procurement function in the public health sector. Some of the key issues addressed are: a) Procurement responsibilities for goods, works and services at the different levels. b) To institutional arrangements for decentralization of procurement responsibilities at the various levels in the health sector. c) The special considerations for procurement of essential medicines and medical supplies; d) The suitable arrangements for procurement of works in the health sector; e) Recommendations on procurement capacity requirements with respect to:  Staffing and skills;  Tools and procedures. The development of the procurement position paper was based on four key pillars in the procurement system. These are:  Transparency  Accountability  Value for money  Efficiency The Paper highlights the procurement responsibilities at the various levels (KEMSA, MOH Headquarters, various KEPH levels), institutional arrangement for procurement like tender committees and procurement committees, procurement capacity requirements, monitoring and evaluation. /8
  12. 12. 1.8 MoH Collaboration with the Faith based organisations Faith Based Organizations (FBOs) continue to be major player in health care delivery in Kenya. Most of them are found in remote parts where people are poor and cannot afford to pay for health care services when sick. In the 1980s, the Government used to set aside funds, which used to be disbursed to FBOs as grants. The decline was a result of funding constraints in the Ministry of Health as a result of improved staff emoluments, increased number of health facilities supported by MOH and overall government budgetary allocation constraints to MOH (9.4% of GOK allocation to health as compared to the Abuja’s target of 15%). The support to FBO was subsequently discontinued in mid 1990s. To date, institutions namely, Kenya Episcopal Conference Catholic Secretariat (KEC-CS) and Christian Health Association of Kenya (CHAK) coordinate the bulk of not-for-profit non-government health providers. Table 1.1 shows the distribution of facilities under the Government and FBOs. Table 1.1: Health facilities by ownership, 2006 Facility type Government KECCHAK CS Hospital 147 44 24 Health centres 460 92 47 Dispensaries 1,630 281 311 TOTAL 2,237 417 382 CHAK/KCS 68 139 592 799 Despite the cessation of funding, the government has continued to deploy some personnel to mission hospitals as well as some assistance with drugs, medical supplies and equipment and vehicles but on an ad hoc basis. Main source of support for the FBOs is currently the user fees which have contributes over 80% of recurrent expenditure. This source, however, is threatened due to decline in donor support to FBOs. Improvement of health care services in public health facilities as resulted in influx of patients to them; this in turn as resulted in reduced utilisation in FBOs facilities and hence reduced revenues. According to a MoH study4 focusing on facility utilisation after the 4 Ministry Of Health: RHF Unit Cost/Cost Sharing Review Study & The Impact Of The 10:20 Policy, 2005. /9
  13. 13. introduction of 10/20 policy on July 1st 2004, which set a standard fee of KSh 10 at the dispensary, level and KSh 20 at health centres, utilisation of services in the sample facilities generally increased rapidly following the introduction of the policy. However, this growth was not sustained. In the last quarter of 2004 many facilities generally experienced declining utilisation although the picture varies by district and according to the type of service and utilisation remains, on the whole, above levels in the first quarter of 2004. In the first half of 2005 utilisation of services at health centres appears to have increased and is now roughly back at the levels experienced in July 2004. Utilisation in dispensaries has seen a slight decline in 2005 although, again, it remains above levels before 10/20 was introduced. This may have led to the subsequent decline in utilisation of FBO facilities and hence decline in their users fees revenue collection. 1.8.1 Current collaboration with FBOs In the context of the Public Service Sector Reforms in general and the Sector Wide Approach (SWAp) in particular, the Faith Based Organisation (FBOs) have effectively participated in the development of the National Health Sector Strategic Plan II (NHSSP II 2005-2010). The FBOs form an important strategic partner in the implementation of the Plan of which collaboration is a key element in its success. There is need, however, to strengthen partnership and collaboration between Ministry of Health and the Faith Based Health Services on a long-term basis. In this regard, a technical Working Group (MOH/FBHS - TWG) comprising MOH, CHAK, KEC, MEDS, and SUPKEM has been put into place. The Minister for Health and Church leaders have approved the terms of reference (TOR) for the Team. The TOR comprise 2 major categories: a) Situation analysis study of FBHS vis-à-vis Health sector Services in Kenya including assessment of Human Resources situation and the various financing options b) Development of a draft partnership policy document guided by SWAp spirit /10
  14. 14. 1.8.2 Progress report on MOH/FBHS - TWG on partnership policy Development a) The Group has been meeting regularly and discussing among other issues, the Human Resources Crisis affecting the faith based facilities after recent recruitment of staff by the Ministry of Health. b) The Group was granted Technical Assistance by development partners for the situation analysis study and has scheduled a 2-day retreat to meet with the consultants to discuss and develop data collection instruments for the study. The situation analysis study outcome will inform the development of the draft partnership policy document to give guidance in the long-term collaboration and partnership. Current Levels of Support to FBO The Kenya Episcopal Conference (KEC) and Christian Health Association of Kenya (CHAK) met His Excellency the President Hon. Mwai Kibaki on 12 th September 2006 to discuss the crisis facing the Faith Based Organizations Health Care Services in Kenya. His Excellency the President directed that Faith Based Organizations discuss with the Ministry of Health on the level and modalities of support and present their report in a month’s time. In response, four technical committees were set up to deliberate and come up with amicable solutions. The outcomes of these committees were as follow: 1.8.3 Immediate re-instatement of financial grant to church Health facilities The Ministry is not able to reinstate the grants to FBOs in 2006/7 financial year, because of current freeze on increment of grants. However, the Ministry has and will continue to support the FBOs in-kind. For example, the total support to FBOs this year in form of drugs and seconded personnel is expected to be KSh 297 million or 1.4% of the Ministry’s recurrent budget. The Ministry will integrate the grant to the FBOs in the MTEF and raise the same to a minimum of 2.8% of the recurrent budget in 2007/8. This grant will be provided in form of drugs, non-pharmaceuticals, personnel, equipments and cash to support operations and maintenance of health facilities. /11
  15. 15. Human Resource for Health issues The biggest challenge, facing the FBOs is shortage of staff. Currently the FBOs require an additional of 6,241 personnel across all medical cadres to close the deficit. To close this deficit, KSh 854 million is required. The situation has been made worse by the fact that the FBOS are having difficulty in paying their workers enhanced salaries to match those offered by the Civil service The Ministry recognizes that the Faith based Organizations are key partners in health service delivery and its collapse will have negative impact on the health sector. In order to support the FBOs, the Ministry has seconded 51 doctors and 44 nurses. The Ministry will second 309 nurses to FBO health facilities this year. This will increase the total support to FBOs in form of personnel to KSh 136 million in 2006/7. The FBOs on their part will use the savings derived from this support to employ additional staff or top-up salaries for their staff to be comparable to those in the Civil Service. Other issues being considered These include the exemption of taxes, licenses and levies 1.8.4 Support in kind through Drugs, Medical Supplies Equipment and Ambulances The Ministry will continue to provide to FBOs support with vaccines, family planning commodities, HIV Test kits, ARV drugs, anti-TB drugs and diagnostic supplies and anti-malarial drugs and ITNs. The current ad hoc arrangement where individual FBO facilities are receiving medical supplies from KEMSA worth KSh 166 million will be discontinued with immediate effect and future support channelled through FBO Secretariats. Twenty ambulances will be earmarked for FBOs in 2006/07 to be distributed to institutions of their choice. 1.8.5 Legal Policy Framework The process is on to develop and recommend partnership framework to be ready by the end of the 2006 with the aim to:   /12 Harmonize FBOs activities in the health sector to reduce competition and duplication; Prioritise facilities in deserving or underserved areas to receive full support from the Government;
  16. 16. 1.8.6 Donor support to the Health Sector The MOH in collaboration with Development and Implementing Partners is developing Sector Wide Approach Strategy (SWAps) that will ensure better harmonization and coordination of planning, implementation and monitoring of activities in the Health Sector. The FBO health facilities, as key implementing partners, will have their Annual Plans and needs included in the Health Sector Annual Operational Plans (AOPs) and supported through the SWAps financing arrangement. 1.9 The Scope and Organization of this Public Expenditure Review This Public Expenditure Review (PER) introduces and then discusses the major dimensions of public financing and expenditure of the health sector in Kenya. It will serve to provide accurate public health spending data for Kenya. In addition to its incorporation of the findings and data of previous PER (2006), this PER provides an update on the public health spending for the five-year period 2001/02 through 2005/06, and analyses several of the important policy issues that are raised and highlighted in these data. This PER concludes by offering some recommendations. Data presented here were gathered and processed by the Central Planning & Monitoring Unit (CP&MU) team in collaboration with Accounts and Finance divisions. This report is divided into twelve parts. Following this Chapter One, which gives relevant background information on Kenya’s health sector, Chapter Two displays and discusses, in summary and in detail, public spending on health during the five-year period 2001/02 through 2005/06. Chapter Three addresses particular issues in review of core poverty/programmes,Chapter Four addresses issues of on-going and stalled projects, chapter Five deals with issues of resource requirement 2007/08-2009/010, Chapter Six analysis the ministry’s out-put and related indicators,Chapter Seven deals with issues of Pending Bills,Chapter Eight deals with public expenditure management (PEM), Chapter Nine deals with issues of human resource development and capacity building, Chapter Ten addresses the implementation of 2006 PER, Chapter Elveen gives the conclusions and recommendations while chapter Twelve concludes with findings and recommendations that derive from the foregoing analyses of the data presented and the policy issues raised and discussed. /13
  17. 17. 1.10 The Ministry’s Mission Statement and Core activities The vision of MoH as envisaged by the Kenya Health Policy Framework for 1994– 2010 is an efficient and high quality health care system that is accessible, equitable and affordable for every Kenyan, which remains appropriate as a guide for NHSSP II. The MoH mission is to promote and participate in the provision of integrated and high quality promotive, preventive, curative and rehabilitative health care services to all Kenyans. Linking to the ERS and MDGs, the mission of the MoH translates into the following set of policy objectives: • • • • • • Increase equitable access to health services. Improve the quality and responsiveness of services in the sector. Improve the efficiency and effectiveness of service delivery. Enhance the regulatory capacity of MOH. Foster partnerships in improving health and delivering services. Improve the financing of the health sector. There are a number of parastatals in the Ministry, namely Kenya Medical Research Institute (KEMRI), Kenya Medical Training College (KMTC), Kenyatta National Hospital (KNH), Moi Teaching and Referral Hospital, Kenya Medical Supplies Agency (KEMSA), and the National Hospital Insurance Fund (NHIF). These parastatals complement the services provided by health centres, dispensaries and district and provincial hospitals. 1.10.1 Kenyatta National Hospital Kenyatta National Hospital through its mandate as provided for in the Legal notice No. 109 of 1987 has the core functions of providing specialised quality health care; facilitation of training and research and participation in national health planning and policy. The hospital has the vision to be a regional centre of excellence in the provision of innovative and specialized health care. The hospital has developed a strategic plan to guide it through 2005 to 2010. Staffing: The hospital has staff strength of nearly 4,700 against an approved establishment of 6,200. This has resulted in understaffing of certain critical areas, such as the nursing department where the patient to nurse ratio is way below the WHO recommended ratio of 1:6. The Plan recognises that it is the staff that will ultimately make the plan a reality. The Plan’s strategic interventions are expected to achieve the following:  Well motivated and committed employees;  More skilled staff;  Right staff for the job; /14
  18. 18.  Competitive advantage;  Increased revenue; and  Overall improved health care delivery. The increased revenue collection will, no doubt, have important implications for the MoH budget. Currently, 12.2% of total MoH budget (13.2% of recurrent and 10.2% of development) is allocated to KNH. The development allocations are a one time support to KNH to support upgrading of equipments. The Poverty Reduction Strategy Paper (PRSP) proposes reduction of the budget allocation for Kenyatta National Hospital, as a share of the total MOH recurrent budget to 10%. Although efforts have been made to reduce allocations to KNH, the current award of salaries to unionisable staff (over Ksh 386 million is required to implement the award) may reverse the gains made so far. Workload: There has been a steady in the inpatient and outpatient workload in the hospital (figure 1.1) resulting in increased pressure on physical, financial and human resources. However, it is apparent that the figures are falling probably as a result of decongestion of the hospital after operationalisation of the Nairobi City Council health facilities through secondment of staff by the MoH. /15
  19. 19. Figure 1.1: In patient and Out patient workload No. of patients (in '000) 800 600 400 200 0 2000 2001 2002 2003 2004 2005 Outpatient Inpatients 1.10.1.1 Financing As seen in Table 1.1, the GoK funding has been below the projected budgetary requirements of the hospital, resulting in non-availability of development funds and inadequate financing of the recurrent expenditure. In 2005/06, out of the KSh 2.9 billion grant from MoH, KSh 2.5 billion was utilised on personnel emoluments while the remaining KSh 0.40 million was used for development and operations and maintenance. The total budget for KNH (including cost sharing) was about 24% of the Ministry of Health Recurrent budget in 2005/6. Table: 1.1 KNH proposed budget and Actual allocations FY Proposed Actual Cost SharingTotal Budget Allocations Collections Allocations+ (MOH) CSF 1999/00 2,075.2 1,359.1 404.5 1,763.7 /16
  20. 20. 2000/01 2001/02 2002/03 1,754.2 5,283.9 5,289.7 1,349.6 1,865.2 2,327.0 534.8 807.1 596.5 2003/04 5,788.0 2,448.0 2,659.0 952.4 2004/05 2005/06 9,733.4 917.2 1,852.1 1,884.5 2,672.4 2,923.5 3,400.4 3,576.2 4,710.1 6,358.0 2,858.0 Source: KNH- Strategic Plan 2005- 2010 As can be seen from the above table the revenue collections at the hospital doubled from Ksh 917 million in 2004/5 with the initiation of computerizations of the collections process. The increased revenue and prudent management enabled the hospital to return a surplus of Ksh 423 million. The impact of this inadequate funding has led, among others to:  Inefficiency in provision of diagnostic services  Prolonged length of stay of patients, for example, in the orthopaedic wards as the hospital is unable to procure required items, thus leading to congestion;  Inability to replace, rehabilitate medical equipment;  Backlog of patients requiring open-heart surgery operations. 1.10.1.2 Impact of Poverty on the hospital The high poverty levels in the country have serious implications on KNH, as majority of patients visiting the hospital are unable to pay for services received. This has threatens hospitals efforts of being self-sustaining, thereby reducing its dependency on the exchequer. Table 2.0: Waivers and exemptions 1999/00- 2003/04 Year Amount (KSh million) 1999/00 128.4 2000/01 146.1 2001/02 130.5 2002/03 180.1 2003/04 98.5 Total 683.6 Source: KNH- Strategic Plan 2005- 2010 /17
  21. 21. Insert figures for 2006/07 As a result of streamlining the waiver issuance process, the levels of waivers heave gone down to 5.2% of the cost sharing revenue in 2003/4. 1.10.1.3 Restructuring Programme The hospital management has developed a restructuring programme to streamline hospital operations. This will include staff rationalisation, computerisation of hospital operations and out-sourcing of non core activities. 1.10.2 Kenya Medical Research Institute (KEMRI) The vision of KEMRI is to be a leading centre of excellence in the promotion of quality health, which will be achieved through research. KEMRI has developed a Strategic Master Plan which also seeks to contribute to the realisation of the MDGs. The Plan also ties with the NHSSP II 2005-2010 whose theme is to reverse the downward trends in Kenya’s national health scene. The new Kenya Essential Package for Health (KEPH), under the Plan puts emphasis on health (rather than disease), on rights (rather than needs) and on revitalisation of health particularly at community level. This ties up well with the KEMRI Strategic Master Plan whose view is to improve not just health but quality of human life. Financial Resource: KEMRI has in 2005, an annual budget of KSh 3 billion. The Government of Kenya provided 50% of the budget while collaborating research partners and organisations provided 45%. The remaining 5% is raised from the Institute’s own internal sources. 1.10.2.1 Achievements Some of the key achievements that have a bearing on the improvement of health status in Kenya as well as contributing to the core activities of the MoH include:  Through the Institute‘s advice to the MoH on rational use of drugs, the malaria drug Daraprim was withdrawn from the market. Chloroquine was withdrawn as a first line drug in the treatment of malaria.  The development of national disease surveillance and rapid response capacity for major disease outbreaks. It is this capacity that has enabled the nation to respond quickly and effectively to yellow fever, rift valley fever and viral haemorrhagic fever outbreaks in Kenya. It is also this capacity that keeps outbreaks, including those for catastrophic diseases such as the Ebola, Marburg, SARS and others away from Kenya.  Development of Insecticide Treated Bed nets (ITN s) for use in the control of malaria. /18
  22. 22.  Development of treatment regimens that have reduced the treatment period for leprosy from 18 months to 1 month (which has almost eliminated leprosy in Kenya); tuberculosis (TB) from 18 months to 3 months and leishmaniasis (Kalazar) from 30 days to 10 days.  Unique contributions in health research technology which includes the development of the KEMRI Hepcell kit for diagnosis of infectious hepatitis, the Particle Agglutination (PA) kit for the diagnosis of HIV and the HLA tissue typing techniques for kidney transplants.  Development of various formulations for treatment of HIV/AIDS and opportunistic infections. KEMRI has also developed a comprehensive training module for HIV/AIDS education awareness at the workplace towards strengthening of HIV/AIDS information, education and communication control initiatives.  KEMRI is a World Health Organization (WHO) collaborating centre for HIV/AIDS, polio immunization, viral haemorrhagic fevers, leishmaniasis, leprosy and antimicrobial resistance. 1.10.3 National Health Insurance Fund NHIF was established through an act of parliament in 1966 with the main objective of financing health care in Kenya. Membership to NHIF is compulsory with a monthly salary of KSHS. 1,000. The current act provides for outpatient and inpatient benefits to members. However, the fund provides inpatient benefits to members only. In line with the Health Sector Strategic Plan II and the ERS objective of improving access to health care, the Government intends to transform NHIF into a social health insurance. In pursuant to the above objective of improving access to health care, NHIF has also enhanced the benefit package to members by establishing a comprehensive inpatient package by extending coverage to include consultation and diagnostic. /19
  23. 23. 1.10.3.1 Contributions and benefit payment Over the years, revenue collection by NHIF has continued to increase. Revenue from contribution from members increased from Kshs. 2.5 billion in fiscal year (FY) 2002/03 to over Kshs. 3.5 billion in FY 2005/06. This can be attributed to mechanisms put in place by NHIF to enhance revenue collection that include enrollment of new members both from the formal and informal sector. During FY 2005/06, NHIF registered a total of 181,583 new members with 10,543 coming from the informal sector. Reimbursement to accredited hospitals also increased from Kshs. 820,000 in FY 2002/03to Kshs. 1.1 billion in FY 2005/06. However, in FY 2003/04 and 2004/05, the reimbursements were on a downward trend due to better claim management through decentralization of operations. The significant increase in reimbursement in FY 2005/06 was attributed to the enhanced rebates to contributors. However, as a percentage of total revenue, reimbursements decreased from 30% in FY 2002/03 to 21% in FY 2004/05. It then increased to 30% in FY 2005/06. The administration5 component of the expenditure recorded a minimal decline over the period under review decreasing from Kshs. 1.62 billion in FY 2002/03 to Kshs. 1.53 billion in FY 2005/06. The administration component has been consuming a significant portion of the total revenues. The administrative component as a percentage of the total revenue recorded a downward trend, dropping from 59% of the total revenues in FY 2002/03 to 42% of the total revenues in FY 2005/06. However, this is still way above the international recommended level for health insurance-10%—12%. 5 Includes personnel and other admin expenses /20
  24. 24.    Table: Growth of members’ contributions 2002/03 REVENUES Contributions 2,523,876,081 6 Other income 210,992,974 TOTAL REVENUES 2,734,869,055 EXPENDITURE Reimbursements Administration 1. Personnel 2. Other admin Total admin expenses TOTAL EXPENDITURE Reimbursements as % of total revenue Total admin as a % of total revenue and reimbursements 2003/04 2004/05 2,639,883,578 3,117,241,202 3,458,847,816 72,358,041 157,349,232 188,463,585 2,712,241,619 3,274,590,433 3,647,311,401 822,014,878 713,297,431 685,490,051 1,105,875,734 776,263,163 846,506,931 827,258,377 704,478,176 1,040,765,820 538,018,321 1,030,516,535 496,191,147 1,622,770,094 1,531,736,553 1,578,784,141 1,526,707,682 2,444,828,033 2,245,033,984 2,264,274,192 2,632,583,416 30 26 21 30 59.34 56.47 48.21 Other medical benefits In line with the funds mandate of enhancing access to health care, NHIF donated 80 Ambulances to GoK hospitals to facilitate transportation of patients from rural health facilities to hospitals where specialized care is required. The fund has also in recent past held several free medical camps in remote areas where access to health care is a major problem. Recommendation In line with the NHSSP II, the funds obligation is to raise benefits to members. In addition, NHIF should strife to reduce administrative costs to 10-12% of the contributions and therefore be in line with acceptable international standard. In addition, NHIF should utilize surplus to pay for additional benefits. 6 Incomes accrued from short and long term investments /21 2005/06 41.86
  25. 25. 1.10.4 Kenya Medical Training College (KMTC) The KMTC, established in 1990, has the following core responsibilities: • • • • • Provide facilities, in addition to those of Universities other colleges, and schools, for college education for health manpower personnel training. Facilitate the development and expansion of opportunities for Kenyans for continuing education in various disciplines of medical training. Provide consultancy and technical advice in health related training and research. Develop health trainers with the capacity to conduct research, develop usable and relevant health learning materials, and manage health-related training institutions. Provide guidance and leadership for the establishment of constituent training centres and facilities. Since its inception, KMTC has managed to establish a number of constituent colleges in a number of district hospitals. These colleges have managed to train a large number of students, many of whom are currently providing services in different institutions in the country. KMTC relies on the government for up to 80% (or Ksh 593 million) of the funding, with the rest generated from student fees, investments, and grants. The proposed harmonisation exercise to equalise salaries and allowances payable to KMTC staff to those in the Civil service will put pressure on personnel allocations to the institution. A total of Ksh 90.8 will be required for the harmonisation exercise. 1.10.5 Kenya Medical Supplies Agency (KEMSA) In 2005, the Health Ministry took a significant strategic leap forward by transforming the Kenya Medical Supplies Agency (KEMSA) from a medical store to a semi-autonomous government agency to provide medical logistics to public health facilities countrywide. KEMSA is mandated to:  Develop and operate a viable commercial service for the procurement and sale of high quality drugs and other medical supplies;  Provide a secure source of drugs and other medical supplies to public health institutions; and  Advise the Health Management Boards and the general public on matters relating to the procurement, cost effectiveness and rational use of drugs and other medical supplies. /22
  26. 26. The National Health Sector Strategic Plan envisioned KEMSA to be “a secure source of essential medicines for all public health facilities”, one of the four key pillars in reducing disease burden and move closer to achieving one of the millennium development goals—to reduce child and maternal morbidity. The other pillars are rational drug use, affordable cost/price and sustainable financing for drugs. Procurement of drugs is based on the 2003 edition of the Essential Drug List. The volume of commodities to be procured is determined by a quantification exercise that is compiled annually by the program managers of MoH in collaboration with KEMSA and the Chief Pharmacist of Ministry of Health. In 2004/5 and 2005/6, KEMSA was enabled to procure the rural health facility kits and hospital pharmaceutical worth Ksh 1.1 billion and Ksh 1.5 billion respectively. it is expected that in 2006/7, all drugs and non-pharmaceuticals will be undertaken by KEMSA in line with the Ministry’s position paper on procurement. Distribution: KEMSA Logistics function aims to deliver medical supplies direct to all health facilities in Kenya consistently and efficiently. In partnership with experienced third party transport service providers, KEMSA has set up a distribution structure with the capacity to reach all public Hospitals, Rural Health Centres and Dispensaries throughout the country. By making timely deliveries against hospital orders with regular deliveries to rural health facilities based on a mutually agreed schedule, KEMSA Logistics will remain versatile and responsive to public customer requirements A process has started aimed at integrating parallel programmes such as Reproductive Health commodities, TB/Leprosy and ARV’s into KEMSA’s overall distribution process. Ultimately, this will cut down on distribution costs and ensure medical commodities are managed within one supply chain resulting in greater reach and efficiencies whilst utilizing limited available resources. The biggest challenge facing KEMSA is lack of funds for capitalisation and for distribution. Discussions are on-going to use the current stocks to capitalise KEMSA and pay for the medical supplies based on delivery. An allocation to cater for distribution will also be made available in 2006/7. 1.10.6 Moi Teaching and Referral Hospital Moi Teaching and Referral Hospital (MTRH) is the second national referral hospital in Kenya after Kenyatta National Hospital (KNH). It was started in 1917 as a cottage hospital with bed capacity of 60, it has grown tremendously to a national referral hospital with a capacity of nearly 500 beds. /23
  27. 27. The teaching and referral facility status was accorded by Legal Notice No. 78 of 12 June 1998 under the State Corporations Act (Cap 446) and the first Board of Management was gazetted on 29 June 1999. A three-year business plan prepared by the Hospital Board of Management immediately after its inception became the first document upon which the board based its actions. The plan articulated the vision and mission of the hospital and set out the organizational structure. It remains to-date the only authentic document guiding major policies on financial management and control, recruitment, and hospital capitalization. However, due to the many challenges posed by rapid developments in the hospital, a Strategic Plan for 2005–2010 has been developed. The hospital is mandated to carry out the following functions:  Receive patients on referral from other hospitals and institutions within and outside the country for specialized health care;  Provide facilities for medical education for Moi University, and for research in collaboration with other health institutions;  Provide facilities for education and training in nursing and other health and allied professions;  Serve as a national referral hospital in national health planning.  It consumes 3.6 % 0f the total MOH recurrent expenditure The 2005/6 allocations to the hospital amounted to Ksh 714 million or 3.6% of the Ministry’s recurrent budget. The hospital will require an additional Ksh 131 million for salary and allowances harmonisation exercise. 1.10.7 Increasing Access Improving access – geographically, financially and socio culturally – generally facilitates increase in the utilization of health care services, as the services become closer and cheaper for the client. This in turn may result in improved health status of the population. In order to improve on physical assess, during the financial year 2006/07, the MoH will (has been) gazette (d), some 600 health facilities, mainly dispensaries that have been constructed using the constituency development fund (CDF). Of these, 300 will be taken over by the ministry and become functional. /24
  28. 28. 2 2.1 Government Spending on Health through the MoH Public Spending on Health: Context Table 2.1 presents as an introduction to a detailed discussion of the trends in Kenya’s public health spending, health economic data for selected countries in the Eastern and Southern African region. Kenya ranks third on per capita public spending and spends 7.2% of total Government spending on health, but this is expected to increase with the recent increase in investment in the health sector. Table 2.1: Total Public Spending on Health - Selected East and Central African Countries, 2005 As a % of As % of Total Country Per Capital (US$) GDP Govt Kenya 2.2 7.2 8 Tanzania 2.7 12.7 7 Uganda 2.1 10.7 5 Zambia 3.1 11.8 11 Malawi 4.0 9.1 5 Zimbabwe 4.4 9.2 14 Rwanda 3.1 7.2 3 Burundi 0.6 2.0 1 Ethiopia 2.6 9.6 3 Source:  UNDP: Human Development Report 2005  WHO: The World Health Report, 2006 2.2 Government Spending on Health: Aggregate Levels and Trends 2.2.1 Total Spending on Health Total government spending on health has risen substantially during the five-year period 2001/02 through 2005/06, increasing from KSh 15.2 billion in 2001/02 to KSh 23 billion in 2005/06 (see Table 2.2). The expenditure growth was uneven. But there is evidence of increasing rate over the previous year occurring since 2003/04- a 7.1% increase in 2003/04, a 16.5% increase in 2004/05, and a 20.1% increase in 2005/06 for combined recurrent and development. /25
  29. 29. Table 2.2: Ministry of Health Actual Expenditure (Gross) KSh million 2001/022002/032003/042004/05 2005/06 Recurrent 12,715 14,405 15,438 17,417 19,765 Development 2,519 945 1,003 1,741 3,242 Total 15,234 15,351 16,441 19,158 23,007 Increase (Recurrent) over previous year (%) 15.2 13.3 7.2 12.8 13.5 Increase (Recurrent + development) over previous year (%)26.2 Per Capita KSh 488.44 Per Capita $ 6.28 Ministry of Health Expenditure (Gross) as % of Total Government1 Recurrent 8.23 Development 17.18 Total 9.01 Ministry of Health Expenditure (Gross) as % of GDP Recurrent 1.38 Development 0.27 Total 1.65 0.8 481.97 6.29 7.1 16.5 506.05 578.28 6.52 7.48 8.69 5.12 8.33 7.76 2.77 6.99 7.66 2.01 6.1 6.29 3.73 5.73 1.4 0.09 1.49 1.41 0.09 1.51 1.41 0.14 1.55 1.29 0.21 1.50 However, these impressive nominal increases in public health spending in 2001/02, in 2003/04, and in 2005/06 did not constitute significant relative changes in resource allocation to health when compared to two important benchmarks - gross domestic product (GDP) and total government spending (in all sectors) - because both grew at similar rates. As a percent of total government recurrent expenditure, therefore, public heath recurrent spending declined slightly over the period, being 8.23% in 2001/02 and 6.29% in 2005/06—even though it rose briefly to 8.69 % in 2002/03. On the other hand, as a percent of GDP, total government health spending rose slightly over the same period, being 1.65 % of GDP in 2001/02 and 1.55 % in 2004/05 of GDP and 1.50% in 2005/06. 2.2.2 Recurrent and Development Expenditure For the period 2001/02 through 2005/06 period, more than half ( ½) (52.7%) of the MoH’s expenditure was on personnel emoluments, 7.5% spent on operations and maintenance and, just about 3% spent on purchases of plants and equipment (see Table 2.3). About 10.5% was spent on drugs and medical supplies and about 26.4% on “transfers” to MOH parastatals. 2.2.2.1 Ministry of Health Recurrent Expenditure by Economic Category /26 20.1 681.78 9.47
  30. 30. Table 2.3 Recurrent (gross) Expenditure by Economic Category KSh millions 2000/01 Total Recurrent (Gross) Salaries and Other Personnel as % Total Recurrent Transfers, Subsidies and Grants as % Total Recurrent Drugs and Medical Consumables as % Total Recurrent Other Operations & Maintenance as % Total Recurrent Purchase of Plant & Equipment as % Total Recurrent Kenyatta National Hospital as % Total Recurrent Moi Referral Hospital as % Total Recurrent 2.2.2.2 2001/02 2002/03 2003/04 2004/05 2005/06 Actual 11,040.8 Actual 12,714.9 Actual 14,405.4 Actual 15,438.5 Actual 17,417.4 Actual 19,765.1 5,251.8 47.6 6,639.9 52.2 7,798.1 54.1 8,100.8 52.5 9,034.9 51.9 10,407.3 52.7 848.1 7.7 1,027.7 8.1 1,157.2 8.0 1,454.7 9.4 1,562.5 9.0 1,634.9 8.3 1,680.8 15.2 1,476.8 11.6 1,349.7 9.4 1,716.0 11.1 1,866.2 10.7 2,074.2 10.5 1,749.9 15.8 1,324.0 10.4 1,257.4 8.7 1,285.2 8.3 1,756.0 10.1 1,481.0 7.5 160.6 1.5 29.0 0.2 94.5 0.7 14.6 0.1 80.7 0.5 595.6 3.0 1,349.6 12.2 0.0 0.0 1,865.2 14.7 352.3 2.8 2,327.0 16.2 421.5 2.9 2,409.0 15.6 458.1 3.0 2,659.0 15.3 458.1 2.6 2,858.0 14.5 714.1 3.6 Ministry of Health Expenditure (Actual) by sub Vote Table 2.4: Ministry of Health Recurrent Expenditures (gross) by Sub Vote KSh Millions Sub-Vote 2000/2001 2001/20022002/2003 2003/2004 2004/05 2005/06 Actual General Admin. And 110Planning Total as % Total MoH 111Curative Health Total as % Total MoH 112Preventive and Promotive Total as % Total MoH 113Rural Health Services Total as % Total MoH Health Training and 114Research Total as % Total MoH Medical Supplies Coord 116Unit /27 Actual Actual Actual 700.7 587.0 714.8 760.4 6.3 4.6 5.0 4.9 6,080.9 6,758.6 7,677.6 7,768.0 Actual Actual 1,223.0 912.527 7.0 4.6 8,639.5 9996.759 55.1 53.2 53.3 50.3 49.6 50.6 874.4 665.2 632.2 863.6 795.9 756.995 7.9 5.2 4.4 5.6 4.6 3.8 1,121.4 1,378.1 1,436.4 1,687.6 10.2 10.8 10.0 10.9 884.2 1,060.2 1,161.8 1,459.8 8.0 8.3 8.1 9.5 8.4 7.6 29.6 48.3 34.2 32.0 132.6 133.177 2,041.5 2881.656 11.7 14.6 1,467.7 1511.916
  31. 31. Total as % Total MoH Kenyatta National 117Hospital 0.3 0.4 0.2 0.2 1,349.6 1,865.2 2,327.0 2,409.0 Total as % Total MoH Moi Teaching and 118Referral 12.2 14.7 16.2 15.6 15.3 14.5 0.0 352.3 421.5 458.1 458.1 714.072 Total as % Total MoH 0.0 2.8 2.9 3.0 2.6 11,040.8 12,714.9 14,405.4 3.6 19, 765.1 100.0 100.0 100.0 Total MoH Total as % Total MoH /28 0.8 2,659.0 2858.014 15,438.5 17,417.4 100.0 0.7 100.0 100.0
  32. 32. Table 2.5: Ministry of Health: Development Expenditures (gross) by Sub Vote KSh Millions. Code 111 112 113 114 116 117 118 General Admin. and Planning Total as % Total MoH Curative Health Total as % Total MoH Preventive and Promotive Total as % Total MoH Rural Health Services Total as % Total MoH Health Training and Research Total as % Total MoH Medical Supplies Coord Unit Total as % Total MoH Kenyatta National Hospital Total as % Total MoH Moi Teaching and Referral Total as % Total MoH Total MoH Total as % Total MoH /29 2000/2001 2001/2002 2002/2003 Actual 110 Sub-Vote Actual Actual 2003/2004 2004/05 Actual 2005/06 Actual Actual 16.9 1,193.2 432.5 196.9 158.7 1.6 47.4 45.8 19.6 9.1 357.213 1 1.0 98.0 637.2 120.1 206.5 9.5 25.3 12.7 20.6 162.0 9. 3 702.779 2 1.7 386.2 134.0 183.4 87.9 37.4 5.3 19.4 8.8 934.0 53. 6 1162.316 3 5.9 248.8 397.7 198.4 446.1 24.1 15.8 21.0 44.5 466.2 26. 8 913.5 2 8.2 281.6 157.3 10.9 65.6 20.0 56 27.3 6.2 1.2 6.5 1.1 1.7 0.0 0.0 0.0 0.0 - 50 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1,031.5 2,519.4 945.3 1,003.0 100.0 100.0 100.0 100.0 - 1.5 - 0 - 1,741. 0 100. 0 0 3,24 1.9 10 0.0
  33. 33. Table 2.6: Ministry of Health Total Expenditures (gross) by Sub Vote KSh Millions CodeSub-Vote 111 Curative Health Total as % Total MoH Preventive and 112 Promotive Total as % Total MoH 113 Rural Health Services Total as % Total MoH Health Training and 114 Research Total as % Total MoH Medical Supplies 116 Coord Unit Total as % Total MoH Kenyatta National 117 Hospital Total as % Total MoH Moi Teaching and 118 Referral Total as % Total MoH Total MoH Total as % Total MoH 2.2.3 2001/2002 2002/2003 Actual General Admin. and 110 Planning Total as % Total MoH 2000/2001 Actual Actual 2003/2004 2004/05 Actual 717.6 1,780.2 1,147.3 957.3 5.9 11.7 7.5 5.8 6,178.9 7,395.8 7,797.7 7,974.5 51.2 48.5 50.8 48.5 1,260.6 799.2 815.6 951.5 10.4 5.2 5.3 5.8 1,370.2 1,775.8 1,634.8 2,133.7 11.3 11.7 10.6 13.0 1,165.8 1,217.5 1,172.7 1,525.4 9.7 8.0 7.6 9.3 29.6 48.3 34.2 32.0 0.2 0.3 0.2 0.2 1,349.6 1,865.2 2,327.0 2,409.0 11.2 12.2 15.2 14.7 0.0 352.3 421.5 458.1 0.0 2.3 2.7 2.8 12,072.3 15,234.3 15,350.7 16,441.5 100.0 100.0 100.0 100.0 Budget Implementation Approved Budgets Actual Expenditures Actual 1,38 1.7 Actual 1 ,269.7 7.2 8,8 01.6 4 5.9 1,73 0.0 5.5 10 ,699.5 9.0 2,5 07.7 1 3.1 1,48 7.7 8.3 3 ,795.2 7.8 13 2.6 46.5 1 ,919.3 16.5 1 ,567.9 6.8 183.2 0.7 2,65 9.0 1 3.9 45 8.1 0.8 2 ,858.0 2.4 19,15 8.3 10 0.0 3.1 23 ,007.0 versus Table 2.7 shows the comparison between approved and actual recurrent and development expenditures by sub vote. While the approved budgets may /30 2005/06 12.4 714.1 100.0
  34. 34. constitute the blueprint for spending, the actual expenditures reveal the true allocation and application of public resources. In a few sub votes there is variance between actual expenditures with the approved budgets. In order to establish where these differences were significant, they were calculated and are presented in Table 2.7, which shows differences by sub vote. It is seen that, while actual recurrent expenditures were either much below or much above the printed and approved budgets in the period 2001/20 to 2003/04, the gap tended to become narrower in 2004/05 indicating that financial management has improved. A comparison between approved expenditure allocations across the main sub votes of expenditure and actual expenditures shows deviations ranging from 5% to 267%. The same significant variations were observed when printed estimated are compared with the actual expenditures. This is however in exception of the 2004/05 financial year. Table 2.7: Actual Expenditures Compared to Approved Annual Budgets for Expenditures on Health, Ministry of Health, and 2001/02 -2005/06. Budget Implementation 2000/01 - 2005/06 2000/01 2000/01 2001/02 2001/02 2002/03 2002/03 2003/04 2003/04 2004/05 2004/05 2005/06 2005/06 Actual Actual as Actual Actual as Actual Actual as Actual Actual as Actual Actual as Actual Actual as as % of % of as % of % of as % of % of as % of % of as % of % of as % of % of Printed Approved Printed Approved Printed Approved Printed Approved Printed Approved Printed Approved Code Sub-Vote Recurrent General Admin. and 110Planning 193 /31 137 141 135 137 132 157 141 135 97 88 84
  35. 35. Budget Implementation 2000/01 - 2005/06 2000/01 2000/01 2001/02 2001/02 2002/03 2002/03 2003/04 2003/04 2004/05 2004/05 2005/06 2005/06 Actual Actual as Actual Actual as Actual Actual as Actual Actual as Actual Actual as Actual Actual as as % of % of as % of % of as % of % of as % of % of as % of % of as % of % of Printed Approved Printed Approved Printed Approved Printed Approved Printed Approved Printed Approved Code Sub-Vote Curative 111Health Preventive and 112Promotive Rural Health 113Services Health Training and 114Research Medical Supplies Coord 116Unit Kenyatta National 117Hospital Moi Teaching 118and Referral Total 153 100 180 154 159 152 152 152 177 99 100 98 176 158 129 126 112 94 86 86 103 94 75 74 36 35 39 34 33 33 33 34 44 102 96 96 115 103 137 101 109 100 100 100 101 100 101 100 70 87 106 83 52 50 46 46 79 98 97 97 100 100 142 100 126 105 100 100 100 100 100 100 267 100 121 100 109 100 100 100 100 100 111 Total Combined General Admin. and 110Planning Curative 111Health Preventive and 112Promotive Rural Health 113Services /32 121 100 106 100 96 97 109 99 98 96 11 23 158 95 50 43 25 32 27 57 35 51 11 22 75 107 14 23 26 60 23 38 46 41 29 39 29 47 24 20 5 8 27 39 27 24 20 25 27 27 10 9 30 25 26 43 38 47 92 99 100 5 5 21 46 2 7 10 9 26 Development General Admin. and 110Planning Curative 111Health Preventive and 112Promotive Rural Health 113Services Health Training and 114Research Medical Supplies Coord 116Unit Kenyatta National 117Hospital Moi Teaching 118and Referral 105 37 71 67 20 19 20 26 22 39 33 33 140 123 152 105 82 74 76 83 92 90 62 71 131 140 160 148 137 140 135 146 157 96 93 90 69 82 82 98 62 51 35 47 41 54 36 33 32 32 35 32 26 25 32 32 39 81 71 77
  36. 36. Budget Implementation 2000/01 - 2005/06 2000/01 2000/01 2001/02 2001/02 2002/03 2002/03 2003/04 2003/04 2004/05 2004/05 2005/06 2005/06 Actual Actual as Actual Actual as Actual Actual as Actual Actual as Actual Actual as Actual Actual as as % of % of as % of % of as % of % of as % of % of as % of % of as % of % of Printed Approved Printed Approved Printed Approved Printed Approved Printed Approved Printed Approved Code Sub-Vote Health Training and 114Research Medical Supplies Coord 116Unit Kenyatta National 117Hospital Moi Teaching 118and Referral Total 108 102 158 101 92 85 86 95 58 85 76 74 70 87 106 83 52 50 46 46 42 91 57 60 99 100 141 100 126 105 100 100 100 100 100 100 267 100 121 100 109 100 100 100 100 100 108 92 84 79 78 83 81 87 76 76 87 91 Table 2.8 shows the trends in actual spending as proportion of the printed and approved budgets by economic categories. There has been improvement for most of the categories, resulting in an improvement of actual expenditures nearly converging to 100% for both printed and approved budget. /33
  37. 37. Figure 2.6: Actual expenditure as % of Approved Recurrent budget by sub vote 180 160 140 120 % 100 80 60 40 20 0 2001/2002 2002/2003 2003/2004 2004/05 General Admin. and Planning Curative Health Preventive and Promotive Rural Health Services Health Training and Research Medical Supplies Coord Unit Kenyatta National Hospital Moi Teaching and Referral Total Table 2.8: Budget Implementation by economic category: 2001/02 2005/06 /34 2005/06
  38. 38. Economic Categories 2001/20022001/20022002/20032002/20032003/20042003/20042004/05 2004/05 2005/062005/06 Actual as Actual as Actual as Actual as Actual as Actual as Actual as % Actual as Actual Actual as % of % of % of % of % of % of of Printed % of as % of % of Printed Approved Printed Approved Printed Approved Approved Printed Approved Total Recurrent (Gross) Salaries and Other Personnel Transfers, Subsidies and Grants Drugs and Medical Consumables Other Operations & Maintenance Purchase of Plant & Equipment Kenyatta National Hospital Moi Referral Hospital 121 100 106 100 96 97 109 99 98 96.30 121 97 102 100 98 100 122 101 102 100.24 135 98 108 100 100 100 98 98 100 99.69 87 99 93 92 80 80 94 94 83 90.17 121 120 108 98 102 95 99 99 90 74.09 85 80 99 98 73 74 95 95 86 94.52 142 100 126 105 100 100 100 100 100 100.00 267 100 121 100 109 100 100 100 100 100.00 Figure 2.7: Ac tual as share ofA pproved Budget : ec onomic c ategory, 2001/02 2005/06 140 120 % 100 80 60 40 20 0 2001/02 2002/03 2003/04 2004/05 2005/06 Total Recurrent (Gross) Salaries and Other Personnel Transfers, Subsidies and Grants Drugs and Medical Consumables Other Operations & Maintenance Purchase of Plant & Equipment Kenyatta National Hospital Moi Referral Hospital Table 2.9: Budget Implementation - Actual as % of Printed and Approved Personnel emoluments by sub vote 2001/02 - 2005/06 Sub vote /35 2001/20022001/20022002/20032002/20032003/20042003/2004 2004/200 2004/200 2005/062005/06 5 5
  39. 39. Actual as Actual as Actual as Actual as Actual as Actual as Actual as % Actual Actual as Actual as % % of % of % of % of % of % of of as % of % of of Printed Printed Approved Printed Approved Printed Approved Approved Printed Approved General Administration and Planning Curative Health Preventive and Promotive Rural Health Services Health Training and Research Medical Supplies Coordinating Unit Total 148 146 165 154 164 171 217.3 103.3 88.4 85.6 209 169 179 170 171 172 208.6 100.0 106.1 103.6 177 163 132 121 114 115 116.7 93.9 71.8 74.9 18 14 14 15 16 16 19.7 112.3 92.0 91.1 123 110 119 115 101 102 127.0 113.1 122.7 113.8 80 73 30 28 23 23 24.7 85.6 77.5 74.2 121 97 102 100 98 100 122.1 100.8 102.3 100.2 Table 2.9.1 Actual as % of Approved- personnel emoluments by sub vote 2001/02 - 2005/06 2000/01 2001/02 2002/03 2003/04 2004/05 General Administration and 141 Planning Curative Health 181 Preventive and 270 Promotive Rural Health 13 Services Health Training 117 and Research Medical Supplies 50 Coordinator Unit Total 101 /36 2005/06 146 154 171 103.3 85.6 169 170 172 100.0 103.6 163 121 115 93.9 74.9 14 15 16 112.3 110 115 102 113.1 73 28 23 85.6 74.2 97 100 100 100.8 100.2 91.1 113.8
  40. 40. Fig ur e 2.8: W ag es and Salar ies: A ctual as shar e o f A ppr o v ed Budg et 300 250 200 % 150 100 50 0 2000/01 2001/02 2002/03 General Admin. and Planning Preventive and Promotive Health Training and Research Total 2.2.4 2003/04 2004/05 2005/06 Curative Health Rural Health Services Medical Supplies Coord Unit Appropriations in Aid (AiA) and Cost Sharing ( ) Table 2.2.5 shows the trends in total recurrent and development Appropriations in Aid (A in A), Table 2.2.6 the Appropriations in Aid implementation while Figure 2.9 illustrates the actual expenditure as a share of the printed estimates and approved expenditure respectively. 2.2.5 Appropriations in Aid (AiA) Table 2.10: Appropriations in Aid (KSh million) 2000/01 2001//002 2002/03 2003/04 2004/05 2005/06 Total Recurrent 73.0 66.3 90.0 57.1 61.4 27.1 Total development 154.2 1,277.5 485.0 328.1 TOTAL 227.2 1,343.8 575.0 385.2 252.9 314.3 505 532.1 /37
  41. 41. 2.2.6 Appropriations in Aid (AiA) 2001/02 2001/02 2002/032002/03 2003/042003/04 2004/052004/05 2005/062005/06 Actual Actual asActual Actual asActual Actual asActual Actual asActual Actual as as % of% ofas % of% ofas % of% ofas % of% ofas % of%of Printed Approved Printed Approved Printed Approved Printed Approved Printed Approved Total Recurrent 158 Total Developmen t 53 TOTAL 55 156 199 100 113 111 101 100 39 39 47 49 16 18 13 15 10 12 14 16 6 8 12 15 15 16 11 12 fig 2.9Actual as share of Approved 1200 1000 800 % 600 400 200 0 2000/2001 2001/2002 2002/2003 2003/2004 2004/05 2005/06 -200 Total Rec urrent Total Development TOTA L 2.2.5 Cost Sharing Cost sharing in public health sector was mooted in the 1984/88 Development Plan and implemented in December 1989 to supplement and complement government resources allocated to the health sector. The revenue collecting health facilities are allowed to retain 75% for use in the improvement of their health care service provision. The remaining 25% of the revenue collected go towards financing the promotive and preventive services in the district. This is in addition to AiA funds. Reporting rates are crucial in providing accurate picture of trends in all cost sharing revenue collection aspects. Facilities are supposed to /38
  42. 42. submit monthly reports on revenue collections, banking, payments and commitments, fee schedules, workloads, financial and workload targets. Trends in cost sharing revenues Table 2.2.7 shows the cost sharing revenue collection trends by province and year. During the financial year 2003/2004, the reported collected revenue was KSh 1,004.93million increasing to KSh 1,099.47million in 2004/05 and further to KSh 1,468.80 million in 2005/06. The rising trend in revenue collection can be attributed to increased reporting rates by facilities; enhancement, strengthening and efficiency improvements in revenue collection through among others, installation of cash registers in some hospitals with heavy workloads as well as, to a small extent, increases in fee levels. Eastern, Central and Rift Valley provinces dominated the total collections each accounting for nearly a half of total revenues collected in 2005/06. Table 2.2.7 Total reported revenue collection by province and financial year (KSh million) Province 2001/2002 2002/03 2003/04 2004/05 2005/06 Central 178.79 217.16 238.27 267.63 324.80 Coast 140.12 162.91 128.42 160.01 151.90 Eastern 141.55 201.37 212.12 207.50 393.40 Nairobi 24.85 35.06 28.88 36.30 64.70 North 5.43 7.20 8.62 17.32 22.50 Eastern Nyanza 93.87 121.47 94.28 128.24 131.10 Rift Valley 181.92 217.53 227.82 210.22 281.10 Western 16.83 70.23 66.52 72.25 99.30 Total 783.37 1,032.94 1,004.93 1,099.47 1,468.80 The Ministry of Health through the Division of Health Care Financing continues with activities geared towards enhancing and strengthening revenue collection and efficiency improvements. The activities include installation of cash registers in hospitals with heavy workloads. 3 3.1 Review of Projects/Programs related to the Ministry Core poverty programs The ministry of health for sometime has not changed her list of core poverty projects/programmes neither the list of those programmes related to the achievement of the MDGs. Most of these projects /programmes are recurrent in nature i.e. yearly or continuous, therefore their expenditure is from GOK. Table 3.1 below shows the trend of the expenditures of the projects/programmes in the /39
  43. 43. ministry. It also reveals that what the projects/programmes spends is much below what they are allocated, these hinders the completion of the planned activities of these projects/programmes. Table 3.1Summary of projects/programmes in the Ministry, 2003/042006/07 Project Name category Year started Year of completion Total Estimated Project cost National Aids Control Programme Sexually transmitted Infection District Hospitals Yearly Continuous Yearly Mental Health Services Spinal Injury Hospitals Rural Health Centres and Dispensaries Health development Project (DARE)) Establishment & equipping for parasite center (KEMRI) Environmental Health Services Communicable & Vector borne Diseases Nutrition Programme Vector borne Diseases control Family Planning Maternal &CHC Rural Health Training & Demonstration Centres Drugs Control Inspectorate KEPI National leprosy &Tuberculosis Kenya Medical Supplies Agency (KEMSA) Specialized & Estimated cost of completion Actual expenditure 2005/06 Allocation 2006/07 Proposed allocation 2007/08 9,609,115 Total cumulative expenditure up-to 2005/06 9,125,563 483,552 9,125,563 10,684,547 11,401955 Continuous 6,768,183 6,234,085.85 534,097.15 6,234,085.85 - - Yearly Continuous 2,452,381,485 1,179,867,848 1,282,513,637 1,179,867,848 1,972,992,347 2,044,496,217 Yearly Continuous 135,427,831 127,476,542 8,051,289 127,476,542 82,776,738 84,571,083 Yearly Continuous 13,301,061 13,199,514 101,547 13,199,514 12,134,443 12,552,080 Yearly Continuous 2,176,117,141 2,160,735,680 2,160,735,680 3,588,338,47 3 4,937,453,015 22,000,000 22,000,000 15,381,46 1 2001 2006 681,500,000 20005 20006 20,000,000 Yearly Continuous 49,473,960 42,800,554 6,673,406 42,800,554 163,361807 222,0555,903 2000 Continuous 8,828,638,073. 109,013,022.60 8,719,625,050.40 109,013,022.60 150,900,005 189,851,105 Yearly Continuous 4,661,174 3,958,733.75 702,440.25 3,958,733.75 4,669,173 5,088,932 2000 2006 11,477,511 10,781,196 696,315 10,781,196 - - Yearly Continuous 46,875,193 45,669,477.90 1,205,715.10 45,669,477.90 46875192 49,918,562 Yearly Continuous 43,672,013 42,305,246 1,366,767 42,305,246 43,680,732 52,569,087 Yearly Continuous 1,516,091 67,347.10 1,448,743.90 67,347.10 1,448,898 1,447,696 Yearly Yearly Continuous Continuous 339,809,001 100,576,800 205,278,124.45 100,440,937.10 134,530,876.55 135,762.90 205,278,124.45 100,440,937.10 487,136,131 100,590,800 488,769,942 120,624,355 2004 Continuous 185,000,000 50,000,000 135,000000 50,000,000 - - 2005 Continuous 980,000,000 1,647,144,236 1,470,500,000 /40
  44. 44. Project Name category & Global Fund Special Global Fund TB Special Global Fund Malaria Year started Year of completion Total Estimated Project cost 2005 Continuous 160,000,000 2005 Continuous Total cumulative expenditure up-to 2005/06 Estimated cost of completion Actual expenditure 2005/06 Allocation 2006/07 Proposed allocation 2007/08 393,777,140 379,479,000 2,134,365,707 1,587,294,225 1,925,668,777 3.2 Analysis of the outputs/outcomes related to these expenditures Execution of a number of the development core poverty programmes within the MOH is likely to achieve the following outcomes: (a) support the ERS goal of delivering pro-poor services by ensuring increased coverage and access to health services; (b) strengthen and support the delivery of primary and preventive services; and (c) reinforce the referral system. /41
  45. 45. The matrix below summarizes the programmes, goals, outputs and indicators. Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom e District Rehabilitation Improve the Most health Hospitals and capacity of all facilities Construction district rehabilitated, of facilities hospitals and improved to infrastructure acceptable and to deliver working quality health conditions. services and Quality health strengthen services health care available closer delivery at the to the district level community through consolidating and reversing the deterioration of physical structures at all facilities Rural Health Minor works, Improve rural All structures in Centres and improvements health rural health Dispensaries and facilities in the centres and rehabilitation country to dispensaries of rural serve rural improved and facilities poor better rehabilitated nation-wide Increased coverage of health services for the rural poor Contribute to decongesting district hospitals and bring services closer to the people Revolving Procurement Improve drug Drugs available Drug Fund and procurement and affordable /42 Indicator Rehabilitation i.e. repairs, re-roofing, repainting, fencing, etc in identified district hospitals completed All structures in rural health centres and dispensaries rehabilitated and improved
  46. 46. Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom e distribution of and in the pilot drugs at distribution, district and its affordable and surrounding. prices, affordability Success and infrastructure lessons from the development, pilot project staff training, replicated in community other districts mobilization Successful and logistical implementation support of the project, and its expansion to the other districts will strengthen KEMSA and make its cash and carry system effective Health Is an Create an Create Development intervention to enabling decentralized Project support environment organizational (DARE) strategies to for structures and better target decentralized management public management systems subsidies to of integrated operational to the poor and HIV/AIDS/TB enhance vulnerable and decentralization Reproductive strategy within Health Services MOH within the districts. Supply of Improve the Increase the Purchase and Medical situation of capacity of improve existing Equipment medical district equipment in equipment in hospitals to various district existing offer hospitals hospitals appropriate Appropriate diagnosis and equipment therapeutic purchased and services delivered to district /43 Indicator Increased immunization coverage Increased contraceptive prevalence, etc Equipment in most hospitals in better and working condition
  47. 47. Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom e hospitals. Rehabilitation Improvement Improve All mortuaries of Mortuaries and facemortuary country-wide lifting of all services all improved, mortuaries over the functioning and country-wide country rehabilitated Environmental Health Reduce the Increased safe Health Services, incidence of water and Services sanitation, environmental sanitation vector control, related coverage waste diseases Reduced vector management, borne diseases drinking water Improved human quality, physical, housing biological and improvement, social pollution environment control, and Improved health sanitary promotion dwellings, eating and work places Mental Health Provision of To provide All structures Services mental health curative care and equipment care services services in in the hospitals to mentally Nairobi area, rehabilitated. sick patients and help Equip mentally Renovation decongest sick patients and KNH, and serve with skills for rehabilitation the densely carpentry and of Mathare populated general repairs Psychiatric eastern of equipment. Hospital, and suburbs of Improve the Gilgil mental Nairobi. health care hospital services for the mentally sick patients. Spinal Injury Hospital /44 Operations and maintenance of individual spinal injury Improve and make accessible affordable Deserving spinal injury patients access health care services. Indicator New mortuaries erected where they do not exist. Construction of demonstration facilities (latrines, domestic water supply) Disease surveillance, sanitary inspection and law enforcement Hospital buildings fully renovated Roads and fences at the hospitals repaired Sewerage system at the hospitals overhauled. Community health workers trained on mental health care Operational requirements for the hospitals such
  48. 48. Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom e health health care Number of facilities services for the patients seeking population care at these with spinal hospitals injury. increased. Sexually Reducing Reduce the risk STIs reduced Transmitted sexually of STI Infection transmitted transmission by diseases providing through preventive research, services clinical services to treat STDs. Communicable and Vector Borne Diseases Nutrition Programme /45 Is an integrated disease surveillance and response involving disease preparedness and response, data management and information dissemination, laboratory support services, training and communication Reduce prevalence of iodine, Vitamin A and Iron deficiencies among Reduced mortality, disability and morbidity due to communicable diseases IDRS expanded to cover up to 80% of the districts nationwide Communication infrastructure such as telephone, radio calls, faxes, and email network initiated in all districts. Incidences of micro-nutrients deficiency related diseases in mothers and children Prevalence rate of iodine, vitamin A and Iron deficiencies reduced. Indicator as chairs for patients, drugs, etc in place. Public information messages, and education programmes Drugs, supplies, equipment to support treatment for STDs Districts trained in emergency preparedness and response. Most health facilities have case information on priority diseases Advocacy conducted IEC materials on micronutrients deficiency
  49. 49. Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom e mothers and reduced children Food control Food safety Incidences of Improved Administration control, food borne sanitary services inspection and illness reduced dwellings, eating licensing, and work places export Enhanced certification personal and and law food hygiene enforcement 3.3 Indicator Health hygiene promotion Law enforcement Sanitary inspections Disease surveillance Ministry’s On-going Projects As shown on Table the Ministry of Health has a total of 126 ongoing projects mainly including rehabilitation and construction of buildings such as mortuary facilities, non-residential and residential buildings in various hospitals, health centres and dispensaries. These projects are those, which had allocations in the budget in 2005/2006, the allocations totalling to KSh 1,036,180,801 million. Table4.1: Ministry of Health's Ongoing Projects - 2005/06 Project KSh Source 1 AFYA House 45,000,000 GOK 2 Coast Provincial general Hospital 35,000,000 Japan 3 Embu Provincial general Hospital 110,000,000 4 Kianyaga Heath Centre 52,000,000 ADF 5 Ngano Health Centre 45,000,000 ADF 6 Kibuga Health Centre 45,000,000 ADF 7 Ngong Health Centre 45,000,000 ADF 8 Kenya Medical Research Institute 20,000,000 Japan 9 Rift Valley Provincial Gen Hospital 10 Kapsabet D.H 11 Nandi Hills D.H. 9,254,640 6,600,000.00 BADEA GOK GOK GOK 3,350,000.00 12 Iten D.H. 13 Kapenguria D. H /46 5,083,000.00 3,274,200.00 GOK GOK
  50. 50. Table4.1: Ministry of Health's Ongoing Projects - 2005/06 Project KSh Source 14 Kitale District Hospital 8,800,000.00 GOK 15 Chebiemit District Hospital 7,158,650.00 GOK 16 Kabarnet District Hospital 3,240,000.00 GOK 17 Molo S.D.H. 3,200,000.00 GOK 18 Gilgil Hospital 3,000,000.00 GOK 19 Naivasha S.D.H 3,000,000.00 GOK 20 Kapkatet District Hospital 3,426,100.00 GOK 21 Nanyuki District Hospital 4,500,000.00 GOK 22 Eldama Ravine D. Hospital 4,000,000.00 GOK 23 Narok District Hospital 4,500,000.00 GOK 24 Kilgoris D.H. 7,000,000.00 GOK 25 Longisa D. Hospital 2,635,000.00 GOK 26 Kajiado District Hospital 4,000,000.00 GOK 27 Loitokitok Sub-District Hospital 3,950,000.00 GOK 28 Maralal D.H. 4,077,400.00 GOK 29 Baragoi SDH 4,000,000.00 GOK 30 Kapkatet District Hospital 5,021,000.00 GOK 31 Nanyuki District Hospital 6,000,000.00 GOK 32 Eldama Ravine D. Hospital 240,000.00 GOK 33 Lodwar District Hospital 3,274,200.00 GOK 34 Eldoret S.D.H. 8,800,000.00 GOK Londiani SDH 7,158,650.00 Kericho District Hospital 2,500,000.00 Kisumu District Hospital 5,960,000.00 New Nyanza PGH 9,831,838.00 Kombewa SDH 7,000,000.00 35 36 37 38 39 40 41 42 43 44 45 46 47 48 /47 Migori District Hospital 10,622,430.00 Awendo SDH 1,500,000.00 Rongo SDH 1,500,000.00 Homa bay District hospital 5,000,000.00 Siaya District Hospital 4,180,000.00 Yala SDH 5,500,000.00 Nyando DH 7,500,000.00 Muhoroni SDH Ogembo D.H 500,000.00 8,604,050.00 GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK
  51. 51. Table4.1: Ministry of Health's Ongoing Projects - 2005/06 Project 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 79 80 81 /48 KSh Bondo D.H. 7,628,200.00 Madiany S.D.H. 4,200,000.00 Rachuonyo DH 5,262,000.00 Suba D.H 6,000,000.00 Kuria D.H. 5,000,000.00 Kisii D.H 2,000,000.00 Keumbu SDH 3,800,000.00 Nyamira DH 3,663,000.00 Nyeri PGH 14,926,345.00 Thika district Hospital 7,116,330.00 Gatundu Hospital 4,000,000.00 Muranga D.H 6,000,000.00 Muriranjas SDH 3,560,000.00 Karatina D.H 3,780,000.00 Mukurweini SDH 3,880,000.00 Othaya SDH 6,000,000.00 Kiambu District Hospital 5,550,000.00 Tigoni SDH 5,450,000.00 Kerugoya District hospital 5,809,477.00 Kimbimbi SDH 7,000,000.00 Nyahururu District Hospital 7,378,210.00 Olkalou SDH 2,000,000.00 Maragua District Hospital 9,288,608.00 Runyenjes SDH 6,000,000.00 Embu PGH 5,406,360.00 Nyambene D.H. 11,635,000.00 Miathene SDH 4,000,000.00 Chuka District hospital 6,514,600.00 Magutuni SDH 4,000,000.00 Meru Central District 8,752,600.00 Githongo SDH 2,000,000.00 Kanyakine SDH 2,580,000.00 Source GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK
  52. 52. Table4.1: Ministry of Health's Ongoing Projects - 2005/06 Project 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 /49 KSh Isiolo District Hospital 3,800,000.00 Marsabit District Hospital 5,152,000.00 Moyale D. H 3,000,000.00 Garbatula S.D.H. 4,975,000.00 Tharaka District 8,240,000.00 Kitui District Hospital 7,270,000.00 SiakagoD.H. 6,200,000.00 Ishiara SDH 2,000,000.00 Makueni D.H 2,200,000.00 Makindu SDH 6,500,000.00 Machakos General Hospital 12,122,000.00 Mbooni SDH 2,000,000.00 Mwingi District Hospital 8,024,952.00 Tseeikuru SDH 6,000,000.00 Kakamega PGH 1,740,000.00 Malava sub-district Hospital 2,009,170.00 Lumakanda D Hopsital 8,873,400.00 Mt. Elgon District Hospital 3,236,000.00 Teso District Hospital 8,943,885.00 Bungoma District Hospital 24,664,360.00 Webuye SDH 4,500,000.00 Port Victoria SDH 6,618,425.00 Alupe SDH 1,500,000.00 Vihiga District Hospital 3,370,000.00 Butere District Hospital 6,000,000.00 Busia District Hospital 5,047,000.00 Coast PGH Hola D.H. 10,586,865.00 Source GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK - Ngao SDH 16,000,000.00 Wesu D.H. 3,000,000.00 Voi DH 7,573,930.00 Taveta Hospital 2,396,114.00 GOK GOK GOK GOK
  53. 53. Table4.1: Ministry of Health's Ongoing Projects - 2005/06 Project 114 115 116 117 118 119 120 121 122 123 124 125 Kwale D.H. Kinango SDH Msambweni S.D.H KSh 10,500,000.00 5,000,000.00 13,460,560.00 Kilifi D.H. 2,000,000.00 Malindi D.H. 2,000,000.00 Port Reitz D.H. 2,000,000.00 Lamu D.H. 2,000,000.00 Garissa DH 6,467,952.00 Wajir D.H 4,245,450.00 Masalani D.H 6,000,000.00 El Wak SDH 6,215,000.00 Rhamu SDH 9,655,700.00 126 Mandera D.H. 4,000,000.00 1,036,180,801 TOTAL (KSh) Source: 2005/06 Estimates of Development Expenditure Source GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK GOK 3.4 Stalled Projects At the same time, there are a total of about 86 stalled projects whose cost of completion is estimated at Kshs.2.12 billion (Annex 1). These stalled projects bear a number of distinct features: • the list include a range of projects whose start up date is early as 1981, and others as recent as 1998; • the completion status is varied, and range from as low as 10% to over 90%; • On average, the majority (almost 79%) of the stalled projects (whose status is known) are 50% and above complete; • Despite being incomplete, the rise in costs to completion may be associated with interest on contract violations, and lack of budget allocations to ensure they are completed. However, a number of the stalled projects have not been abandoned since they were included in the budget estimates for 2004/2005 as shown in Table 6 – /50
  54. 54. 3.5 New projects TO BE INITIATED IN 2006/07 CHAO TO PROVIDE INFORMATION-CHERUYOIT TO FOLLOW UP – NO NEW PROJECTS SO FAR 3.6 Weakness in Project implementation Judging from the long list of stalled projects, the varied status of completion, and amounts of money needed to complete them, including the large difference between the original and current costs, a number of weaknesses become apparent: • A clear policy or decisions to check cost escalations on these projects seems to be lacking. This may be a government-wide problem and not MOH specific. • Similarly mechanisms for monitoring and evaluating the progress of projects seem to be lacking. Such a mechanism, if combined with an appraisal process, would allow decisions to be made on current and ongoing projects before new commitments are made, and additional project costs included in the budget for the MOH. • The appraisal should include stiff criteria for verifying new projects. Where possible, completion of ongoing projects ought to be part of the criteria and conditions for initiating new ones. 4 Pending Bills Unpredictability of the budget leading to, in particular, variations between the budget, and budget out-turns leaves the wide gap between estimates and actual expenditures. Together with delays caused by the existing capital project procurement policy, the accumulation of pending bills has become a problem, and to non-completion and stalling of development projects. 0. As summarized in Table 5.1, the MOH accumulated a total of KSh. 158.3 million in pending bills for both recurrent and development for the period under review . The larger proportions (96%) of the pending bills were for development costs, /51
  55. 55. mainly for rehabilitation and construction. It will be noted that pending bills have increased by over 40% from last year and this is likely to increase further if bills are not paid in advance. There is a down ward trend of bills under utilities in the recurrent vote but with the development vote the trends is increasing. This calls for more funds to be allocated to the development vote in order to finish the planned projects in advance. Table 5.1 2004/05 Vote head/type Description Utilities (mainly water) Telephone Other Recurrent Total recurrent Development 2005/06 mount (KSh) Amount (KSh) 57,781,145 35,275,301 11,000,000 25,449,434 94,230,579 4,527,230 3,447,390 Total (recurrent + Development) % of Total MOH expenditure 97,677,969 0.5 39,802,531 118,479,103.30 158,281,634.30 0.07 5.1 Recommendations • • • • • /52 Further disbursements should be accompanied by implementation guidelines especially for RHF’s The DHMB’s should be enabled/empowered to oversee implementation of projects and defect omissions/mistakes early enough i.e not leaving every thing to the ministry of Roads and public works alone Processing of AIE’s and subsequent of funds should be done within the 1st quarter of the Financial year allows proper planning/adequate consultation with Management Committees Facilities that were not funded in 2005/06 should be prioritized in 2006/07(see attached list). Improving budget predictability.
  56. 56. • • • 5 5.1 Recognizing and increasing the budget for operation and maintenance expenditures such as supplies, utilities, communication, etc. At present, approved budgets are not matched with timely release of exchequer funds by the government. A review of current procedures governing the release of certified and voted funds is needed in order to avoid delays, and to facilitate overall improvement in the implementation of the budget. As revenues and resources for health improve, the MOH needs to add medical supplies, maintenance and repairs especially at the rural health facilities to its list of protected budget items as is the case for selected expenditures for core poverty programs Analysis of Ministry outputs and corresponding performance indicators Output targets Table 5.1 shows the outputs and targets for selected indicators. These indicators are intended to measure the performance of the MoH as past of its commitment to the Economic Recovery Strategy (ERS). Table 5.1: Health Sector Indicator Targets7 Indicator Measure Base 2005 2006 2007 line Achieved8 Target Target 2003 (%) 1. Proxy for Fully Immunized 57 61 67 70 Infant Children (FIC) as a % of Mortality under-one population 2. Proxy for Percentage of pregnant 10.1 6.4 8.4 8 HIV/AIDs woman attending ANC prevalence who are aged 15-24 who are HIV-infected 7 8 The BOP did not extend the targets to 2008/09. Current status(achievements) /53
  57. 57. 3. Proxy for Percentage of ANC 54 Maternal coverage (4 Visits) Mortality 56 65 70 4. Proxy for Inpatient malaria 19 Burden of morbidity as percentage Disease of total in-patient morbidity 18 15 14 5.2 Overview of Sector Performance Indicators and Targets Overview of Sector Performance Indicators and Targets, NHSSP II/AOP 2, 2006/07 /54
  58. 58. Achievement Baseline National Targets 05/06 Achievement for reporting districts (61) Projected national achievement Performance against target 42% 51% 15% 15% 30% 80 28 28 35% Indicators Below 80% Achievement %Deliveries conducted by skilled health staff District Aqua Laboratories in place # School children correctly dewormed at least once in 2005/06 # HIV+ve patients starting with ART 25% 35% 7% 13% 36% 8,000 95,000 38,320 38,320 40% % Pregnant women sleeping under LLITN # LLITN distributed to children under 5 yrs 0.44 44% 20% 20% 45% 250,000 3,400,000 1,181,959 1,798,739 53% % WRA receiving FP commodities 10% 20% 11% 11% 57% % Pregnant women attending four ANC visits 54% 70% 44% 44% 62% 80,000,000 90,000,000 37,422,850 66,030,516 73% 74% 84% 64% 64% 76% % Children fully immunized at 1 year of age 58% 68% 56% 56% 83% Blood collected screened for HIV 0.98 1 1 1 100% 8 7 8 100% 90% 99% 99% 111% # Condoms distributed (million) % Children < 1yr vaccinated against Measles Above 80% Achievement Regional Food/Bacteriological Lab. Established % Newborns that receive BCG # Health Facilities providing Basic/Comprehensive Emergency Obstetric Care (BEOC / CEOC) # Houses sprayed with IRS % Pregnant women received IPT 2x LLITN distributed to pregnant women % House Holds implementing hygiene practices # HF providing treatment as per IMCI guidelines # HF offering Youth Friendly Health Facilities # CORPs selected and trained 5.3 84% 9% 15% 18% 18% 122% 2,500 200,000 367,000 367,000 184% 4% 20% 43% 43% 214% 55000 200000 251,872 456,771 228% 25% 58% 58% 234% 10% 35% 35% 353% 2% 5 5 47 47 940% 100 10024 10024 10024% Links Budget allocation to Output Delivery Public management promotes a direct link between results based public health sector management and the budgetary process. Health budgets are allocated based on the variables of which some are outputs. The budgeting system quite rightly assumes that budgets cannot be realistically based on the delivery of outcomes. These are often medium term objectives and are influenced by a /55
  59. 59. number of variables, some not within the control of the health sector; and their monitoring is a very complex task. The direction and strategies outlined in NHSSP II are to be implemented through development and implementation of annual operational plans (AOPs). In addition, a four-year Joint Programme of Work and Funding (JPWF), developed concurrently with the plan, outlines the interventions the sector will focus on in the medium term, their costs, financing and finance gaps. The JPWF also describes the financing strategy the sector will use to mobilize the resources needed to close the gaps. The linkages among NHSSP II, the JPWF and the various AOPs are illustrated in Section 2.5. Among others, the elements of NHSSP II are:  Creating linkages from NHSSP II to the overall development objectives as expressed in the Economic Recovery Strategy for Wealth and Employment Creation 2003–2007 (ERSWEC), and the achievement of the Millennium Development Goals (MDGs).  Renewing attention to the right to health care and the importance of good health at the household, family and community level.  Introducing the Kenya Essential Package for Health (KEPH), which integrates all health programmes into a single package to improve the health of the population in the different stages in their life cycle and incorporates the various systems that will support KEPH.  Proposing to change the governance of the sector by institutionalizing and improving the relations between MOH and all stakeholders.  Starting to apply public sector reforms within the health sector (like performance-based contracts for all those responsible in the civil service).  Initiating a sector-wide approach (SWAp) in the health sector, through joint planning and joint performance monitoring, as well as a process to arrive at a harmonization of funding arrangements. 5.4 Expected Outputs and Outcomes 2006/07 5.4.1 Human Resource In order to address the long-term manpower needs for the health sector, an assessment is being conducted to identify the human resource requirements to meet the MDGs. This report is expected to form the basis for a human resource development policy including training need assessment. /56

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