Kenya’s Health Sector Budget: How Aligned is it to the Child National Health Priorities?

Kenya’s Health Sector Budget: How Aligned is it to the Child National Health Priorities? International Society for Child Indicator’s (ISCI) Conference, held in York, UK 27th – 29th July 2011 Government ofKenya Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e, The opinions expressed are the personal thoughts of the contributors and do not necessarily reflect the policies or views of the institutions or any other organization involved and named in this paper

Outline • Introduction • Data and Methods • Results • Discussions By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

introduction By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Kenya’s Profile • Location: • East Africa; • Borders Somalia and Indian Ocean in the east; Ethiopia and South Sudan in the North; Uganda in the West and Tanzania in the South. • Population: 38.6 million (males – 49.8% and females – 50.2%). • Approximately half of the population is poor. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

In 2009/10, most health indicators for children and women were off the set sector targets • Source: Republic of Kenya (RoK), 2011. Second Annual Progress Report on the Implementation of the First Medium Term Plan (2008 – 2012), Nairobi: Government of Kenya. A. K. Mwenda

Preventable diseases/conditions continue to be the leading causes of In-Patient Mortality for under fives in Kenya Source: Health Management Information System, 2008 as cited in RoK, 2011b. Health Situation Trends and Distribution 1994 – 2010 and Projections for 2011 - 2030. Nairobi: MoMS and MoPHS. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Situational Analysis of Children and Women Health • Nutrition: • National prevalence rates of stunting , wasting and underweight children have remained almost stagnant at approximately 35%, 7% and 20% respectively. • The national averages of children nutritional status also mask regional disparities. • Sanitation • Most households (53.7% of the poor households and 40.2% of the non-poor households) in Kenya use unsafe drinking water and live in environments characterised by poor sanitation. • Among the poor households only 1 in 5 access piped water, compared to 2 in 5 non-poor households. • Diarrhoea and intestinal worms infestation that are linked to unsafe water, together accounted for approximately 10% of the outpatient visits in 2008 (RoK, KDHS 2009). A. K. Mwenda

Situational Analysis of Child and Women Health • Immunisation • Although, national immunisation coverage has increased from 57% in 2003 to 77% in 2008/09, poor health seeking behaviour and long distances to health facilities have hindered the equitable coverage of immunisation programmes. As a result, the country has not attained the set target of 85%. • National average mask significant regional disparities. • Reproductive health care • Although the country has a high coverage of Antenatal Care (92%), only 44 percent of the deliveries are conducted under skilled care, either by a nurse, midwife or a doctor. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Data and methods By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Data and Methods • Qualitative and quantitative data • Data verified by government officials – to confirm accuracy and solicit explanation • Assessment criteria: • Adequacy of budgetary allocation by comparing country data to international benchmarks and other countries • Health sector allocative efficiency • Criteria for identifying children’s programmes • Relative impact on children compared to other population groups • Programme that target women but have implication on the health of children. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

results By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Kenya lags behind comparable developing countries like Rwanda and Botswana that spend more on healthcare Source: UNDP, 2009. Human Development Report and WHO, 2011, Data and Statistics, http://www.who.int/research/en/ By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Although the budget for the health sector increased in nominal terms, as a share of total public expenditure it dropped from 7.4 percent in 2004/05 to 5.8 percent in 2008/09. Source: MoMS, 2009; MoPHS, 2009 By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Adequacy of Public Health care Spending • At the current level of public spending on health care, financial targets have not been achieved leading to a funding gap. • As a result, the per capita total expenditure on health was US $ 105 in 2006, falling short of the average for the Sub-Saharan Africa at US $ 147.8. • The current public health care financing level is also way below the per capita resource requirement for the Kenya Essential Package of Health (KEPH) programmes estimated at US $ 35.2 in 2009/10 (Ministry of Health – MoH, 2005a) • Health sector development expenditure has been inconsistent and unpredictable, reflecting the unpredictability of external financing and regular economic shocks. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Examples of KEPH services and charges: These charges, though nominal may be the ‘difference’ between life and death but most households can hardly afford. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Adequacy of Public Health care Spending • The Kenya government has aligned its health allocation with a pro-poor focus by increasing spending for Primary Health Services (especially in health infrastructure development) • BUT there has not been commensurate increase in the budget allocation for permanent employees and hence the ministries of health are not able to attract and retain high calibre staff (there is 1 doctor for every 5,700 people in Kenya). • Accelerated development of health infrastructure is depleting common pool resources available for the provision of other public services. • Health ministries also face difficulty in procuring and sustaining adequate and equitable provision of essential healthcare supplies and equipments. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Public expenditure on children and women-related programmes has been less than 10 percent of the total public health sector expenditure. Source: RoK, various. Printed Estimates of Recurrent Expenditures; RoK, various. Printed Estimates of Development Expenditures. KEPI – Kenya Expanded Programme on Immunization. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Mismatch of children and women health care demands and financing • Nutrition: In 2007/08, less than 0.02 percent of health sector budget of KSh. 25.6 billion was allocated to the Nutrition Division within the MoPHS. In 2008/09, only 0.14 percent of the total health sector budget was allocated to the Nutrition Division. • Reproductive Health Care: A significant proportion (38.4% in 2005/6) of the total reproductive health expenditure is borne by households through the out-of-pocket OOP payments. In 2008/9, only 1.8 percent of the overall government expenditure on health was spent on reproductive health services. • Immunization: Budget allocation for immunization programme did not exceed 1 percent between 2003/4 and 2009/10. • Sanitation: Management of sanitation and hygiene programme needs better coordination across the several ministries involved. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Child and women programmes over-rely on donor funds which are unpredictable Source: RoK, various. Printed Estimates of development expenditure. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Over 90% of donor funds are managed outsides the mainstream government budget and are disbursed in kind. • This denies the implementing agencies • The flexibility to determine the quality of goods and services delivered • Reduces the ability of agencies to respond to emergencies By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Adequacy of Health Care Finance • The low per capita spending and heavy donor reliance as well as inadequacies in the provision of health care services reflects a huge financing gap in the health sector. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

User fees lower public health sector efficiency: Increase in user fees in public sector facilities lowers utilisation of health care services, diverts demand to private and mission facilities BUT does not shift demand to traditional health care providers. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Mechanisms through which user fees may lower efficiency in the Public Health sector • Leakage of revenue and therefore loss of opportunity to improve public health care services (MOH, 2006). • District Health Management Boards (DHMBs) do not have full authority to determine the use of the funds they collect. They are required to submit budgets to the headquarters for approval. As a result, DHMBs do not have the incentives to improve their efficiency. • Planning division of the ministry headquarters is not appropriately staffed to effectively supervise and coordinate the collection of user fees. • In some cases user fees waivers and exemptions are diverted to non-deserving patients, resulting in loss of opportunity to improve health care delivery (MoH, 2006). By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

User fees enhance inequality in health care access: The higher the proportion of financial burden imposed on patients by cost sharing, the lower the chances of them accessing treatment. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

User fees enhance inequality in health care access: User fees are a regressive mode of financing health care since they impose disproportionately higher costs of health care on the poor and the chronically ill. Annual Per Capita Outpatient Visits to Government Facilities and the OOP Spending on Outpatient Care as a % of HH Expenditure, by Expenditure Quintiles, 2007. Source: Author’s computation based on RoK, 2009b. HH Health Expenditure and Utilisation Survey Report 2007 By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

discussion By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Lessons • Public health sector spending has been increasing but is still below the recommended international standards and that of many comparable countries. This limits access to health care among children and women. • It is evident that majority of the patients in Kenya seek health care services in government facilities. Naturally, therefore when funding for public health care is disrupted: • Household budgets are disrupted as many people seek health care services in the more expensive substitute (private and mission) facilities. • Alternatively, health care may not be viewed as a priority, leading to delayed treatment and ultimately catastrophic health care costs • Tax revenue and donor finance (as demonstrated above) are susceptible to external shocks such as financial crisis, foreign exchange fluctuations, political conflicts and climate change. These shocks in turn affect the sustainability of health care financing. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Lessons • BUT children and women programmes rely heavily on donor financing which is unpredictableand inadequate to fully fill resource gaps e.g. unfair staffing. • Households bear a significant proportion of the total health expenditure owing to high user fees. • User fees are a highly regressive mode of financing, requiring the poor and the chronically ill to pay disproportionately higher amounts for health care, than the rich. This limits access of health care services by certain groups (especially children and women). By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Some Proposals • The government should progressively increase budgetary allocations to children and women programmes and reduce the programmes exposure to unpredictable donor funding. • In order to enhance allocative efficiency, there is need to institutionalise district consultations through the Social Budgeting Framework. • In order to tap into private sector finance and enhance efficiency in public health care, government should forge partnerships with the private sector e.g. through lease agreements for provision of health care supplies and equipments. • In the long run, the government should pursue policies that seek to eliminate user fees for health care services, especially in facilities that are mostly used by the poor. • In this regard, the government should consider expanding the social health insurance coverage. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Some Proposals • Deepen the “Health Sector Services Fund (HSSF) ” components that are meant to address ‘equity issues’ in health for children and women in deprived communities and vulnerable populations. HSSF is an innovative direct transfer of funds to dispensaries and health centres, started on 28th October 2010, with Ksh. 143 million disbursed to 590 health centres across Kenya. By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Thank you By Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,

Kenya’s Health Sector Budget: How Aligned is it to the Child National Health Priorities?