HEALTH SECTOR WORKING GROUP REPORT

REPUBLIC OF KENYA kin HEALTH SECTOR WORKING GROUP REPORT MEDIUM TERM EXPENDITURE FRAMEWORK (MTEF) FOR THE PERIOD 2013/14-2015/16 OCTOBER 2012

TABLE OF CONTENTS LIST OF TABLES AND FIGURES... 1 LIST OF ABBREVIATIONS... 1 Executive Summary:... 3 CHAPTER ONE... 6 1 INTRODUCTION... 6 1.1 Background... 6 1.2 SITUATION ANALYSIS... 6 1.2.1 The Health Profile... 6 1.2.2 Human Resources... 7 1.2.3 Physical Infrastructure... 7 1.2.4 Commodity Supplies and Management... 8 1.2.5 Health Care Financing... 8 1.2.6 Research and Development... 9 1.2.7 Devolution... 9 1.3 Sector Vision and Mission... 10 1.4 STRATEGIC GOALS AND OBJECTIVES of the Sector... 10 1.5 Sub Sector and their mandates... 10 1.5.1 Medical Services Sub-sector... 11 1.5.2 Public Health and Sanitation sub-sector... 11 1.5.3 RESEARCH AND DEVELOPMENT SUB-SECTOR... 11 1.6 Autonomous and Semi Autonomous Government AGENCIES... 12 1.6.1 Kenyatta National Hospital (KNH)... 12 1.6.2 Moi Teaching and Referral Hospital (MT&RH)... 12 1.6.3 Kenya Medical Training College (KMTC)... 12 1.6.4 Kenya Medical Supplies Agency (KEMSA)... 13 1.6.5 National Hospital Insurance Fund (NHIF)... 13 1.7 ROLE OF SECTOR STAKEHOLDERS... 13 CHAPTER TWO... 15 2 PERFORMANCE AND ACHIEVEMENTS OF the SECTOR DURING the PERIOD 2009/10-2011/12... 15 2.1 PERFORMANCE of Programmes... 15 2.1.1 Medical Services sub-sector... 15 2.1.2 Public health and sanitation sub-sector... 17 2.1.3 Research and Development Sub-Sector... 20 2.2 Review of key indicators OF SECTOR performance... 22 2.2.1 Medical services... 22 2.2.2 Public Health and Sanitation... 23 2.2.3 Research and Development sub sector... 24 2.3 Expenditure Analysis... 26 2.4 Analysis of Recurrent expenditure... 27 2.5 Analysis of Development expenditure... 27 2.6 Analysis of Externally Funds Programmes... 28 2.7 Expenditure review by programmes... 30 2.8 Review of Pending Bills... 34 2.9 Recurrent Pending Bills... 34 2.10 Development Pending Bills... 34 CHAPER THREE... 36

3 medium term priorities AND FINANCIAL PLAN for the MTEF PERIOD 2013/14 2015/16... 36 3.1 Introduction... 36 3.2 Prioritization of programmes... 36 3.3 programmes and their objectives... 37 3.4 PROGRAMMES, SUB- PROGRAMMES, EXPECTED OUTCCOMES, outputs, AND KEY PERFOMANCE INIDCATORS for the sector... 39 3.5 PROGRAMMES BY order of ranking... 42 3.6 Analysis of Resource Requirement versus allocation by:... 42 3.7 Sector resource requirements... 42 3.7.1 Sub-Sector (recurrent and Development)... 42 3.7.2 Programmes and sub-programmes... 43 3.7.3 Semi-autonomous government agencies... 44 3.7.4 Economic classification... 44 3.8 Resource allocation criteria... 45 3.8.1 Gross resource requirements... Error! Bookmark not defined. 3.1.1 Resource requirements by sagas... Error! Bookmark not defined. CHAPTER FOUR... 46 4 CROSS-SECTOR LINKAGES, EMERGING ISSUES AND CHALLENGES... 46 4.1 INTRODUCTION... 46 4.2 INTRA SECTOR LINKAGES WITHIN SUB SECTORS IN THE HEALTH SECTOR... 46 4.3 Links to other SECTORS... 46 4.3.1 Energy, Infrastructure and ICT Sector... 46 4.3.2 Environmental Protection, Water and Housing Sector... 47 4.3.3 Social Protection, Culture and Recreation Sector... 47 4.3.4 Public Administration and International relations... 48 4.3.5 Education Sector... 48 4.3.6 Governance, Justice, Law and Order Sector... 49 4.4 EMERGING ISSUES... 49 4.4.1 Devolution... 49 4.4.2 Burden of Communicable and Non- Communicable diseases... 50 4.4.3 The Public Health Security and Bioterrorism Preparedness and Response. 50 CHAPTER FIVE... 51 5 CHALLENGES IN HEALTH SECTOR... 51 5.1 INADEQUATE RESOURCES... 51 5.2 Access, transport and Equity... 51 5.3 Health Service Delivery... 51 5.4 Human Resources... 51 5.5 Donor Funding... 52 5.6 Early Teenage Pregnancies... 52 5.7 Child Health, maternal and reproductive health:... 52 5.8 Nutrition:... 52 5.9 Monitoring and Evaluation... 52 CHAPTER six... 54 6 CONCLUSIONS... 54 CHAPTER seven... 56 7 KEY RECOMMENDATIONS... 56 8 REFERENCES... 58 2

LIST OF TABLES AND FIGURES Table 2.2-1: Performance of Health status indicators in the Medical Services Sub- Sector 2009/10 2011/12... 22 Table 2-2: Performance of Health status indicators in the Public Health and Sanitationsub-sector 2009/10 2011/12... 23 Table 2-3: Sector Actual Expenditure (Net in Kshs. Millions) 2009/10 to 2011/12... 26 Table 2-3: Recurrent Actual Expenditure (Net in Kshs. Millions) 2009/10 to 2011/12. 27 Table 2-4: Development Actual Expenditure (Net in Kshs. Millions) 2009/10 to 2011/12... 27 Table 2-5: Analysis of externally funded programs 2009/10 to 2011/12 (Kshs. Millions)... 28 Table 2-6: Analysis of Expenditure by Programme (Gross in Kshs. Millions) Medical Services sub-sector... 30 Table 2-7: Analysis of Expenditure by Programme (Gross in Kshs. Millions)- MOPHS... 32 Table 2-8: Analysis of Expenditure by Programme(Gross in Kshs. Millions)- Research and Development... 33 Table 2-9: Summary of Recurrent Pending Bills by nature and type (Kshs Million)... 34 Table 3-1: Programmes and Sub-Programmes... 37 Table 3-2: Programmes, sub-programmes and their outputs and outcomes... 39 Table 3-3: Total health sector requirement for FY 2012/13 2015/16 (KES Million)... 42 Table 3-4: Sector requirement for both recurrent & development FY 2012/13 2015/16... 42 Table 3-5Programme and Sub- Programme requirement for FY 2013/14 2015/16... 43 Table 3-6 Semi autonomous Government Agencies FY 2012/13 2015/16... 44 Table 3-7 Health Sector requirement by economic classification for FY 2012/13 2015/16... 44

LIST OF ABBREVIATIONS ACUs AIDS Control Units AIA Appropriations in Aid AIDS Acquired Immune Deficiency Syndrome AIE Authority to Incur Expenditure AKF Aga Khan Foundation ART Anti Retro Viral Therapy ARVs Anti Retro Virals BOPA Budget Outlook Paper CBOs Community Based Organizations KNBS Central Bureau of Statistics CDF Constituency Development Fund CIDA Canadian International Development Agency DANIDA Danish International Development Agency DFID Department for International Development EMMS Essential Medicines and Medical Supplies FBOs Faith Based Organizations GAVI Global Alliance Vaccination Initiative GDP Gross Domestic Product GF Global Fund GFATM Global Fund Aids TB and Malaria GoK Government of Kenya HIV Human Immuno Deficiency Virus HSSF Health Sector Services Fund ICT Information and Communication Technology IFMIS Integrated Financial Management Information System IRS Indoor Residual Spraying ITNS Insecticide Treated Nets JICA Japanese International Corporation Agency KDHS Kenya Demographical Health Survey KMTC Kenya Medical Training College Kshs Kenya Shillings M&E Monitoring and Evaluation MDGs Millennium Development Goals MOF Ministry of Finance MOMS Ministry of Medical Services MOPHS Ministry of Public Health and Sanitation MPER Ministerial Public Expenditure Review MTEF Medium Term Expenditure Frame Work NGO Non-Governmental Organizations NHSSP National Health Sector Strategic Plan O&M Operation and Maintenance OBA Output Based Approach OVC Orphans of the Vulnerable Children PE Personal Emoluments PEPFAR Presidential Emergency Plan for Aids Relief PMTCT Prevention of Mother to Child Transmission SAGA Semi-Autonomous Government Agency

STD SWAP TFR UNICEF UNFPA USAID USAMRU VCT WB WHO Sexual Transmitted Disease Sector Wide Approach Total Fertility Rates United Nations Children's Fund United Nations Population Fund United States Agency for International Development US Army Medical Research Unit Voluntary Counselling and Testing World Bank World Health Organization 2

EXECUTIVE SUMMARY The Health sector has the overall goal of providing equitable and affordable health care to Kenyans at the highest affordable standards. These Health Sector Group Working (SGW) paper for MTEF period 2012/13-2014/15 presents an analysis of the Sector performance, achievements and the resource requirements for the period 2012/13-2014/15. The sector has three programmes namely; 1. Preventive and Promotive Health Care Services 2. Curative Health Care Services 3. Research and Development The health sector has achieved considerable outcomes as per its mandate: reduction of Under Five Mortality from 115 per 1,000 live births in 2003 to 74 per 1,000 live births in 2008/9 and Infant Mortality from 77 per 1000 live births to 52 per 1000 live births in the same period. The sector has also seen increased immunization coverage for under 1 year olds from 71% in 2008 to 77% in 2011. However, the sector still experiences some challenges especially regarding the high disease burden. Maternal Mortality Ratio has deteriorated from 414 in 2003 to 488 deaths per 100,000 live births in 2008-09; Births attended by skilled health personnel declined from 51 percent in 2007 to 43 percent in 2010/11, despite considerable funding flowing to the programmes. Even with the increasing allocation to the sector, Public Per Capita spending currently stands at $19.2 and in general, Per capita health spending still remains low at $42 compared to the WHO recommendation of $54 per capita. Expenditure analysis During the period of review, the sector saw increased expenditure; from KES 37.8 Billion in 2009/10, 42.2 Billion in 2010/11, to KES 58.9 Billion in 2011/12. The sector absorption capacity of the approved budget was at 87.3 %, 81.8 % and 87.1% in 2009/10, 2010/11 and 2011/12 respectively. The low absorption capacity was mainly due to lack of reporting on A-in-A by Development Partners. The Health Sector had a total of KES 1,442.4 Million in pending bills for both recurrent and development for the period under review. Pending bills due to lack of liquidity were at 99.7 percent, while those due to lack of provision were also 0.3 percent. Expenditure review by programmes Allocations to the Curative programme increased during the period under review from actual expenditures of 26.8 billion in 2008/09 to 29.3 billion in 2011/12. Recurrent actual expenditures rose from 23 billion in 2009/10 Financial Year to 27.5 billion in 2011/12. In 2011/12 Financial Year, the Ministry spent 53 per cent in compensation to employees, 32 per cent in Grants, transfers and subsidies. The Ministry spent the least in acquisition of Non-financial assets at only 5 percent. Further Development expenditures decreased from 3.7 billion in 2009/10 to 1.7 billion in 2011/12. 3

Recurrent allocations and expenditures generally dominate overall Medical Services sub-sector. In the Preventive and Promotive health programme, actual recurrent expenditures totalled Kshs 12.4 billion in 2011/12, up from Kshs 6.1 billion in 2009/10. Compensation to employees (personnel emoluments) accounted for 36% of the total expenditure during 2011/12 FY which is a decrease from 41% in 2009/10 FY. However, in absolute terms, the Ministry s health spending on personnel emoluments has increased, but there is still a shortage of health workers. Expenditure on goods and services (O&M), grants, transfers and subsidies and acquisition of non-financial assets accounted for 48 percent, 11 percent and 5 percent respectively in 2011/12 financial year. In the Research and Development programme, the institute receives a one line budget which is used both for operations and capital expenditure. Personal emoluments utilised 13%, Acquisition of Non-Financial Assets 82 % and Use of Goods and Services 5% of the budget in 2011/12. In the MTEF period from 2013/14 2015/16, the sector will endeavour to maintain the current gains and improve on the priority areas. In this regard, the requirement for the period is KES 174, 677 Billion, 224,834 Billion and 316,232 Billion for the 2013/14, 2014/15 and 2015/16 respectively. Emerging Issues In the Constitution health service delivery is a two tier system whereby the National Government will focus on Health policy, National Referral Hospitals, Capacity Building and Technical Assistance to Counties. On the other hand the County Health services will focus on County Health Facilities and Pharmacies, Ambulance Services; Promotion of primary Health Care; licensing and control selling of food in public places; veterinary services, cemeteries, funeral parlours and crematorium; referral removal; refuse dumps and solid waste. This scenario will need concerted effort in restructuring organizational arrangement in relation to human resource management, infrastructure development and maintenance, health financing, donor funding and partnerships. Cases of Communicable diseases such as HIV/AIDS, Malaria, Pneumonia, TB and Cholera have been a major concern. Similarly high reported cases of noncommunicable diseases like cancer, hypertension, heart diseases and diabetes are increasingly becoming a major health problem. In addition, road traffic injuries are also significant causes of death. The contribution of injuries and non-communicable diseases to total morbidity and mortality is projected to increase, placing new challenges on the health system. This high disease burden is complicated by the high cost of medical care and poverty levels in the country. In the recent past the country has witnessed the potential disease outbreaks like Ebola and HN1virus which call for additional resources allocation for response and containment of contain, prepare and respond to such emergencies. Where policies are nonexistence there is need to formulate the same for operational purposes and establish emergency centres in strategic locations in the country. 4

Conclusions The Health Sector was allocated Kshs. 93 billion in FY 2013/2014. During the medium-term planning period, the sector emphasis will be on strengthening of health systems particularly focusing on high impact interventions and priority investment areas. To accelerate this process, the Sector will focus on progressive improvement of governance frameworks, health infrastructure, human resource for health, social health protection and access to quality and affordable medicines and medical supplies across the country. This will ensure achievement of the necessary standards and norms required for effective and comprehensive health service delivery. 5

CHAPTER ONE INTRODUCTION 1.1 BACKGROUND This Health Sector Group Working (SGW) paper for MTEF period 2013/14-2015/16 presents an analysis of the context, Sector performance, achievements and the resource requirements for the period 2013/14-2015/16. The Health Sector comprises of Ministries of Medical Services, Public Health and Sanitation, Research and Development sub-sectors, namely KEMRI. The main purpose of the report is to provide policy makers, donor agencies and other stakeholders with the information they need to make appropriate policies and funding decisions. The goal of Kenya s Vision 2030 for the Health Sector is to provide equitable and affordable health care at the highest affordable standards to her citizens. Good health is a prerequisite for enhanced economic growth, poverty reduction and a precursor to realization of the Vision s Social Goals. Further, the Constitution under the Bill of Rights states that access to healthcare is a right to every Kenyan. It is against this background that the Health Sector is re-positioning itself to fulfil the expectations of Kenyans through various strategic interventions through improved health systems such as infrastructure and service delivery. 1.2 SITUATION ANALYSIS 1.2.1 THE HEALTH PROFILE According to the Kenyan epidemiological profile, disease burden is still high. Top five causes of outpatient morbidity namely Malaria, Diseases of the Respiratory System, Skin Diseases, diarrhoea, and accidents account for about 70 percent of total causes of morbidity. Malaria contributes about a third of total outpatient morbidity. The leading causes of mortality are: Infectious and parasitic diseases (42 percent of total mortality in 2008) followed by Diseases of Respiratory System (11 percent), and Diseases of Circulatory System (7 percent). The incidence of non-communicable diseases especially cancer continues to rise with over 82,000 new cases and 18,000 deaths (third among the causes of death in Kenya) reported annually. HIV prevalence estimates vary widely across regions, but the latest estimates from the 2008/09 Kenya Demographic and Health Survey (KDHS) place the prevalence rate at 6.3 percent, slightly lower than the previous estimate of 6.7 percent (KDHS 2003). Although this reduction is small in terms of number of cases as compared to the total population, sustenance of effective prevention programmes are required for keeping infection rates low in the future. The Government efforts jointly with Development Partners and other stakeholders, have resulted in reversing the downward trends in health status indicators observed in the 1990s. Remarkable achievements have been made in the reduction of Under Five Mortality from 115 per 1,000 live births in 2003 to 74 per 1,000 live births in 2008/9 6

and Infant Mortality from 77 per 1000 live births to 52 per 1000 live births in the same period. The proportion of children fully immunized against communicable diseases increased from 64 percent in 2005/06 to 77 percent in 2009. The declining maternal health indicators are worrying. Maternal Mortality Ratio (MMR) has deteriorated from 414 in 2003 to 488 deaths per 100,000 live births in 2008-09. Births attended by skilled health personnel declined from 51 percent in 2007 to 43 percent in 2010/11. According to the 2008/09 KDHS Nutritional status of children has also not shown significant improvement over the years. An estimated 16 percent of children under-five years are underweight, 7 percent are wasted, and 35 percent are stunted compared to 2002/03 KDHS where an estimated 20 percent of children under-five years are underweight, 5 percent are wasted, and 30 percent are stunted. Regional level health indicators show that North Eastern, Coast, Nyanza and Western Provinces have the worst infant and child mortality indicators. High poverty levels and inadequate environmental sanitation among other factors are the contributing factors to these differentials. 1.2.2 HUMAN RESOURCES Kenya has an average of 19 doctors and 173 nurses per 100,000 population, compared to WHO recommended minimum staffing levels of 36 and 356 doctors and nurses respectively. Regarding the optimal staff establishment, the sector would require 72,234 staff. Currently the sector has an approved staff establishment of 59,667 but only about 49,096 positions are filled, leaving 10,371 positions vacant. The Research and Development (R&D) sub-sector has developed a critical mass of human resource to conduct health research. Currently the number of research personnel (in post) stands at 204. Poor working conditions remain a major challenge. These have resulted in brain drain which is adversely affecting research and development capacity in the sector. In the recent past, the health sector has witnessed industrial unrest by the health professionals agitating for increased remuneration which has serious budgetary implications within the sector. The shortages of Human Resource and industrial unrest have had negative impact on the Sectors capacity to deliver services. 1.2.3 PHYSICAL INFRASTRUCTURE The health system in Kenya comprises Public, private-not-for-profit (PNFP) and privatefor-profit (PFP) providers as well as traditional practitioners. From the available records (Master Facility List), the total number of facilities in the country is 7,608. The Ministries of Health continue to be a major provider of health care services in the country through a network of hospitals, health centres, and dispensaries. The public sector owns and operates 55% of the total health facilities. Private and FBO health facilities complement the provision of health care by the government through the 7

remaining 45 percent (FBOs 14 % and Private 31 %) of health facilities. Private-for- Profit (PFP) facilities are clinics that provide about 80 percent of outpatient curative services. Although the Government has put a lot of efforts in rehabilitating and upgrading health facilities in the country, there is still need to invest more in infrastructure particularly in equipments and technology.. Accessibility to the health facilities is estimated at 52 percent based on the 5km radius norm. However, there are variations in access in different parts of the country, with the worst areas being in the Northern part of the country. Kenya currently lacks adequate infrastructure and administrative mechanisms to exercise governance of research subsector. Because research and innovation are key drivers of development, strengthening national research capacity provides both an effective means and practical course of action for increased technical, social and economic development in the country. Strengthening national research capacity through substantial and sustained investments can help improve health care, and to achieve greater autonomy, development and equity. 1.2.4 COMMODITY SUPPLIES AND MANAGEMENT Kenya Medical Supplies Agency (KEMSA) is responsible for the procurement, storage, and distribution of medicines and medical supplies in public health facilities. However, the greatest challenge of the Agency relates not only to efficiency and supply chain management but also its future role in the devolved system of government. The Sector currently receives just about 50 per cent of the required funds for essential medicines and medical supplies. Currently Development Partners support over 90 percent of funding for ARVs. This situation is not sustainable in the long run and poses a major risk to the lives of HIV/AIDS patients in the event that development partners support declines. As a result patients are forced to purchase over the counter medicines, leading to risk of drug resistance due to under/over-dosage. 1.2.5 HEALTH CARE FINANCING Public financing for the Sector (recurrent and development) was estimated to be about 1.9 percent of GDP and the public per capita health spending was $19.2 in 2011/12. In general, per capita spending on health care according to NHA 2009/10 remains at $34 However, this amount remains inadequate when compared to the WHO recommendation of an average of $44 per capita spending on health care. In FY 2011/12 the overall allocations increased from 7.6 to 7.8 percent of the overall Government budget. Funding for health research remains donor-driven, fragmented, and uncoordinated, and priority setting at both at the national level remains unclear. 8

Public funding for Research and Development is limited to personnel emoluments with no direct funding for research and other core mandate activities. The donor funding is predominant in all aspects of research and operations as well as development. About 99 percent of research in KEMRI is funded by the development partners. These funds are expended as per the individual donor budget mainly supporting research activities which often may not be priority for Kenya. These programmes are not sustainable in the long run and they are affecting the policy formulation in the Sector 1.2.6 RESEARCH AND DEVELOPMENT Currently, health research is conducted, managed, and financed by a diverse number of Organizations. However, they have demonstrated limited coordination, accountability and impact analysis of the research on the critical needs of the Health Sector. As a result our talented young researchers with excellent ideas, have no opportunities to submit a research proposals and face a bleak and uncertain future in health research. Current funding systems orient these researchers to the interest of external donors instead of to the health needs of their country, and force them to publish in journals that they often cannot access. In view of the above, the health sector will develop an explicit research policy and legal framework to guide research activities by various institutions in Kenya. 1.2.7 DEVOLUTION The promulgation of the Constitution was a major milestone towards the improvement of health standards. The Constitution has raised high expectations for the citizens in general through the provisions of the Bill of Rights. It stipulates the right to the highest attainable standard of health, which includes the right to reproductive health and emergency treatment. The sector acknowledges the great opportunities for improving health care as well as the challenges to be overcome during the implementation process under the new dispensation. The sector in consultation with the various arms of the governments including the independent institutions will continue to collaborate and dialogue to ensure establishment of devolved structures and systems to support seamless provision of health care during the transition period. In this regard significant resources will be required during this MTEF period to support implementation of change management during the transition period within the sector and specifically progressive improvement of counties to effectively provide equitable, affordable and quality health care. 9

1.3 SECTOR VISION AND MISSION The Draft Kenya Health Sector Strategic Plan III (2013-2017) sets out the Vision and Mission of the Health Sector as: Vision A healthy and globally competitive nation Mission To deliberately build progressive, responsive and sustainable technologically-driven, evidence-based and client-centred health system for accelerated attainment of highest standard of health to all Kenyans To fulfil the vision and mission, the Health Sector provides leadership through formulation of health policies and strategic direction, setting standards and provision of health services through public facilities and regulation of all actors/services. 1.4 STRATEGIC GOALS AND OBJECTIVES OF THE SECTOR The following policy objectives aim towards the realization of the Health Sector Vision: Eliminate communicable conditions: This is to be achieved through reducing the burden of communicable diseases, till they are not of major public health concern. Halt, and reverse the rising burden of non-communicable conditions. This is to be achieved by ensuring clear strategies for implementation to address all the identified non communicable conditions in the country. Reduce the burden of violence and injuries. This is to be achieved by directly putting in place specific strategies in collaboration with stakeholders in other sectors that address each of the causes of injuries and violence at the time. Provide essential health care. These shall be medical services that are affordable, equitable, accessible and responsive to client needs. Minimize exposure to health risk factors. This aims at strengthening the health promoting interventions, which address risk factors to health, plus facilitating use of products and services that lead to healthy behaviour in the population. Strengthen collaboration with other sectors. This aims to adopt a Health in all Policies approach, which ensures the Health Sector interacts with and influences design implementation and monitoring processes in all health related sector actions. 1.5 SUB SECTOR AND THEIR MANDATES 10

1.5.1 MEDICAL SERVICES SUB-SECTOR The Sub Sector vision is To be an efficient and high quality medical services that are accessible equitable and affordable for every Kenyan. In line with the Vision, the Mission of the Medical Services sub-sector is to promote and participate in provision of integrated quality curative and rehabilitative services for all Kenyans. The mandate of the Medical Services Sub Sector is to ensure availability of medical care and improve lives through responding to health care needs of the population in Kenya. 1.5.2 PUBLIC HEALTH AND SANITATION SUB-SECTOR The Sub Sector vision is to have a nation free from preventable diseases and ill health. In line with the Vision, the Mission of the Public Health and Sanitation Sub-Sector is To provide effective leadership and participate in the provision of quality public health and sanitation services that are equitable, responsive, accessible and accountable to all Kenyans. The mandate of the Sub Sector is to support the achievement of the highest attainable Public Health and Sanitation goals of the people of Kenya, with special focus on community (Level I); dispensary (level II), and Health Centers (Level III) structures. 1.5.3 RESEARCH AND DEVELOPMENT SUB-SECTOR The development of the necessary scientific infrastructure, technical and entrepreneurial skills, is an essential ingredient for the transformation of Kenya into a middle income country. The Kenya Medical Research Institute (KEMRI) is the body mandated by the Science and Technology Act of 1979 to conduct research in human health, disseminate and translate research findings in health for evidence based policy formulation and implementation. The Vision for R&D Sub-Sector is To be the leading global centre of excellence in human health research, and the Mission is; To improve human health and quality of life in Kenya through biomedical research, innovations and capacity building. The R&D Sub-Sector has been borne out of the realization that Kenya must harness in a coordinated manner, the best possible human capital and research technology which will position the country in modern world economy that is increasingly globalized and knowledge based. R&D will therefore lay the foundation for attainment of scientifically and technologically advanced society by supporting the national development strategy based on the Kenya Vision 2030. Mandate of R&D Sub-Sector; 11

To conduct research aimed at providing solutions for the reduction of the infectious, parasitic and non-infectious diseases and other causes of ill-health in Kenya To provide leadership in research for Health To promote and sustain excellence in research for health To strengthen principles of Good Corporate Governance To disseminate and translate research findings for evidence-based policy formulation and implementation. To strengthen research partnerships and collaborations with other stakeholders 1.6 AUTONOMOUS AND SEMI AUTONOMOUS GOVERNMENT AGENCIES The Health Sector has autonomous and semi-autonomous organizations that perform specialized functions. The organizations include: Kenyatta National Hospital; Moi Teaching and Referral Hospital; Kenya Medical Supplies Agency; Kenya Medical Research Institute; National Health Insurance Fund; Kenya Medical Training College. 1.6.1 KENYATTA NATIONAL HOSPITAL (KNH) The Mandate of KNH is to receive and treat patients on referral for specialized care from other hospitals and health institutions within and outside Kenya; provide facilities for medical education for the University of Nairobi and for research by directly or indirectly cooperating with other health institutions within and outside Kenya; provide facilities for education and training in nursing and other health and allied professions and participate in national planning and policy formulation. 1.6.2 MOI TEACHING AND REFERRAL HOSPITAL (MT&RH) The mandate of MT&RH is to 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. 1.6.3 KENYA MEDICAL TRAINING COLLEGE (KMTC) KMTC is mandated to provide facilities for education in 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; empower health trainers with 12

the capacity to conduct research, develop usable and relevant health learning materials, and manage health-related training institutions; and provide guidance and leadership for the establishment of constituent training centers and facilities. 1.6.4 KENYA MEDICAL SUPPLIES AGENCY (KEMSA) KEMSA is mandated to procure, offer for sale and supply medicine and medical supplies; establish warehouse facilities for storage, packaging and sale of medicine and medical supplies to health institutions; conduct analysis of medicine and medical supplies to determine their suitability; advice consumers and health providers on cost effective use of medicine. 1.6.5 NATIONAL HOSPITAL INSURANCE FUND (NHIF) The mandate of the NHIF is to provide accessible, affordable, sustainable and quality social health insurance through effective and efficient utilization of resources to the satisfaction of contributors. The core activities of NHIF include registering and receiving contributions; processing payments to the accredited health providers; carry out regular internal accreditation of health facilities and contracting health care providers as agents to facilitate the Health Insurance Scheme. 1.7 ROLE OF SECTOR STAKEHOLDERS The Health Sector has a wide range of stakeholders with interests in the operational processes and outcomes. Some of the stakeholders who play important roles in the Sector include the following: (i) The Ministry of Finance plays a major role as a stakeholder by providing the budgetary support for investments, operations and maintenance of the Sector s ministries besides the remuneration of all employees within the Sector; (ii) The Ministry of State for Planning, National Development & Vision 2030 plays a crucial role in coordination in planning, policy formulation and tracking of results in the sector. (iii) The Ministry of State for Public Service provides the relevant schemes of service for career development; (iv) Development Partners play a critical role in providing financial support for various programmes within the sector; (v) The Ministry of Local Government, Parliament, Universities, NGO, FBOs in the Health Sector and the private sector also play crucial roles in augmenting sector funding ; (vi) Kenya National Bureau of Statistics (KNBS) and Kenya Institute of Public Policy Research and Analysis (KIPPRA); conduct surveys and provide information for planning purposes. (vii) Others are the Ministry of Water and Irrigation, Ministry of Agriculture, Ministry of Environment, Ministry of Roads and Public Works and Ministry of Education. 13

(viii) International collaboration on matters of public health is a critical component in driving the process forward in prevention of diseases, sharing and partnering on public health best practices. Towards this effect Health Sector collaborates with WHO, CDC and other international bodies whose mandates is to contain, research, or disseminate findings on health matters. At local level the Sector collaborates with Public universities and research bodies in order to generate public health knowledge for benefit of the country. Other international key stakeholders in include UNICEF UNFPA, DANIDA, GIZ, ADB, JICA, Italy, France, USAMRU (US Army Medical Research Unit)World Bank, among others. (ix) Households, and communities have a role in resource mobilization and management of the sector programmes at all levels of care; 14

CHAPTER TWO PERFORMANCE AND ACHIEVEMENTS OF THE SECTOR DURING THE PERIOD 2009/10-2011/12 1.8 PERFORMANCE OF PROGRAMMES This Chapter examines performance of the health sector, public resource allocations between 2009/10 and 2011/12 as well as the expenditure efficiency and equity issues. It reviews the total amount of resources to the health sector from government and attempts to provide a consolidated picture of the available resources for the Health Sector. 1.8.1 MEDICAL SERVICES SUB-SECTOR 1.8.1.1 Service delivery The Ministry continue to support implementation of KEPH as defined in the National Health Sector Strategic Plan II. Some of the selected service delivery achievements include: a) The overall HIV prevalence rate among adults 15 49 years has decreased from 6.7 per cent in 2003 to current 6.3 per cent in 2008-09 (KDHS). There has been relative success in scaling up access to Anti-Retroviral Treatment from 363,421 in 2009/10 to currently 540,000 persons; b) Increase in mothers delivering in hospitals was due to implementation of hospital reforms, reduced hospital based on under five mortality due to improved nutrition. c) Reduced mortality from respiratory infections from 31.9% in 2010 to 26.3% in 2011. During the review period the emergence of non-communicable disease has necessitated a paradigm shift from the traditional communicable disease this double disease burden put a lot of constraints on the available resources for curative services. 1.8.1.2 Human Resources for Health (HRH) The ministry has over the period promoted over 6000 health workers under the implementation of the common cadre expansion exercise. This was a plan across the entire public service to expand the job groups which form common cadre bracket to four grades after entry point. This move was meant to address stagnation and succession management problems among employees. Despite high staff turnover mainly due to resignations and retirements, the ministry has been recruiting 715 doctors and 200 graduate nurses interns annually on temporary terms. As they undergo their internship they strengthen the regular staff by reducing the workload in the hospitals hence improved service delivery. In addition it has been the practice to absorb all the doctor interns into regular establishment upon completion 15

of their internship, though this move has met strong challenges during budgeting. Furthermore, the period under review has seen recruitment of 568 administrative support staff including cooks, accounts clerks and mortuary attendants. This has improved cash collection in hospitals and ease staff shortage in the facilities which were adversely affected. In- service trainings courses are approved quarterly to enable health workers to further their studies. This has equipped employees with skills and competencies necessary for improving service delivery. The introduction of extraneous and emergency-call allowances has boosted staff morale though the varying rates created grievance and disharmony to certain cadres of health workers which led to industrial unrest. The rates were later harmonised. Recently the ministry introduced the GHRIS which enables staff access their employment details online including downloading of payslips. Application for employment numbers for new appointees to MSPS is now being done online. Other achievements include: a) Comprehensive HRH strategic plan was developed to address Italia s issues of staff recruitment, deployment, training among health workers; b) There has been a significant increase of middle level trainees at Public Medical Training Colleges from 4,957 in 2009 to 6,969 in 2011. c) Several key changes in personnel structure have occurred over the last three years mainly as a result of recruitments, absorption of staff previously working under donor funded projects, trainings and promotions. The period is also marked by improved career progression due to implementation of the circular on common cadre expansion to cover the first four grades at entry point. 1.8.1.3 Commodities and Supplies a) The Ministries of Health scaled up the demand driven PULL system of distributing Essential Medicines and Medical Supplies (EMMS) to the Facilities. b) Defined drawing rights for health facilities for EMMS; c) KEMSA Board was re-constituted and launched; Enterprise Planning System implemented and other institutional reforms are on-going. d) Capitalization of KEMSA to stock Essential Medicines and Medical Supplies. 1.8.1.4 Health infrastructure a) One hospital (Mama Lucy Hospital) constructed 48 hospitals upgraded and 92 rehabilitated. b) Referral facilities equipped with renal equipment s (KNH, Coast PGH, Rift Valley PGH, Nyanza PGH, and MTRH). KNH also equipped with one cancer equipment. c) A Comprehensive master inventory of health facilities developed to address the issues of duplication of data and errors in the data sets. 16

In this regard, the Ministry strengthened HMIS in 224 hospitals and financial systems against a target of 150 hospitals. 1.8.1.5 Health Care Financing a) In the period 2009/10 to 2011/12, direct transfers of funds to over 270 hospitals was implemented through the HMSF to improve health financing; b) Draft health financing strategy developed and shared with National Economic and Social Council and key stakeholders in the health sector; c) According to National Health Accounts Survey, Households expenditure has been reducing, 54% in 2001/02, to 39% in 2005/06 and 37% in 2009/10; d) Total numbers of members plus dependants covered through NHIF increased from 4 Million in 2006/07 to 12.3 million 2011/12.The total contribution revenue has increased from Kshs 3.1 billion in FY 06 to Kshs 5.6 billion in FY 10 and Kshs 9.4 billion in FY 2011. e) Cost-sharing, revenue collections have increased from Kshs2.1billion in 2009/10 to Kshs 3.5 billion in 2011/12. The increment has been attributed to Health care financing reforms instituted. 1.8.1.6 Governance and Leadership a) Training in health systems strengthening -undertaken to improve leadership & management of public hospitals; b) Implementation of AOPs to operationalize strategic plans. c) During period the Ministry undertook the following with a view to ensuring conducive policy environment: - (i) Reviewed of health policy framework; (ii) Developed e-health strategy; (iii) Developed national health training policy; (iv) Developed a Public Private Partnership strategy; (v) Developed health financing strategy; and (vi) Initiated review of Health-related Acts. d) developed the draft Health Policy Framework 2012-2030 and submitted to Cabinet for approval 1.8.2 PUBLIC HEALTH AND SANITATION SUB-SECTOR 1.8.2.1 Reduction of Malaria related deaths and prevalence With an increasing coverage of effective malaria tools such as long lasting insecticide treated nets, use of effective medicines and indoor residual spraying, the subsector realized 44 per cent reduction of child mortality in malaria endemic districts and a 13 per cent reduction in outpatient attendances. The malaria indicator survey 2010 showed a marked reduction of malaria prevalence in Coast province from a high of 30 per cent to 8 per cent. The prevalence however remains more than 30 per cent in parts of Nyanza and Western provinces. 17

1.8.2.2 Recruitment of health workers; The subsector is labour intensive. During the period under review the subsector recruited 5,768 nurses, 769 Public Health Officers and 2093 Community Health extension Workers (CHEWS) under the Economic Stimulus Programme. To strengthen equitable distribution of staffs especially in hard-to-reach areas the subsector through the support of the Development Partners recruited and deployed 543 health workers (Nurses, PHOs and Clinical Officers these staffs were eventually absorbed by the subsector. In order to establish with certainty the human resource capacity in the two subsectors initiated HR mapping exercise. Consultative process with the stakeholders is on-going with a view to mobilize resources for its implementation. In addition, the subsector rolled out performance appraisal system at the national and sub-national levels, in conjunction with Development Partners, 2,000 health workers were inducted. Similarly, another 30 senior health workers were trained on strategic leadership skills and other 20 health workers were trained in specialized areas at post graduate levels. Under the review period, the Ministry s health worker performance was improved through performance appraisal system roll out at national and sub-national levels. In order to foster staff attraction and retention, the ministry implemented the approved extraneous and emergency call allowances applicable to health workers. In the same period, the Ministry reviewed two schemes that is, for Public Health officers and Nutritionists. 1.8.2.3 Improved efficiency in procurement of goods and services During the period under, the subsector scaled up demand driven PULL system of distributing Essential Medicines and Medical Supplies (EMMS) to the Primary Health Facilities. The system is based on the needs and the financial allocation of the individual facility. As part of the deepening institutional reforms in KEMSA, the subsector undertook capitalization of KEMSA to enable it to adequately stock the essential medicines and medical supplies needed by the facilities. Consequently the previously experienced drug stock out has been minimized. 1.8.2.4 Construction of model health centres; To accelerate the achievement of the flagship project of infrastructure development, the subsector embarked on construction of 201 model health facilities in the constituencies. These facilities are in different phases of completion: As of end of FY 2011/12, 133 facilities were 100% complete with 98 facilities operational; 45 facilities were between 90% and 99% completion while 14 facilities were between 70% and 85% in addition, to cater for emergencies in the model health centers, 43 ambulances were purchased and distributed to different constituencies. 18

1.8.2.5 Health Information Systems (HIS) Effective public health information system is critical for policy and operation decisions making processes. To facilitate this process the subsector initiated upgrading of health information system to ensure accurate and consistent information data base. During the period under review the subsector developed an online inventory of all health facilities. The subsector also developed and rolled out a modular web-based software package for reporting and analysis of health related indicators by the Districts, District Health Information System (DHIS) 1.8.2.6 Health Care Financing During the period under review the subsector embarked direct disbursement of funds to health facilities. This included training and re-orientation of staffs at all levels (Provincial Health Management Teams), DHMTs & District treasuries. Currently, 718 Health Centers and 2,291 dispensaries are receiving the funds. A total of 1.2 Billion has been disbursed to the primary health facilities and DHMTs between November 2010 and June 2012. 1.8.2.6.1 Increasing access to subsidized RH services through the OBA Vouchers As part of supporting the sector to scale up social health protection, the subsector initiated and commissioned Output Based Approach (OBA) voucher programme to improve access to quality Reproductive Health (RH) and Gender Based Violence (GBV) recovery services. This programme targeted economically disadvantaged and vulnerable women and children. The programme was piloted in Kitui district and has now been scaled up to five counties (Kisumu, Kiambu, Kitui, Kilifi Nairobi). As a result of the programme, 224,966 and 36,216 women have benefited from safe mother hood and family planning services respectively. During the plan period the programme recorded an increase in facility based deliveries of the target population from the national average of 43% to 74%. 1.8.2.6.2 Enhancing integration of health financing through the Sector-Wide Approach (SWAp) Fostering partnerships has been one of the major goals of reforms undertaken in the subsector jointly with Partners in Health. During the plan period the subsector together with two Development Partners (Danida, and World Bank) signed Joint Financing Agreement (JFA) which established the pooled funding currently supporting Health sector Services Fund and Essential Medicines and Medical Supplies. Similarly the subsector continued to engage and dialogue with other Development Partner under the Sector Wide Approach (SWAp) mechanism. 1.8.2.7 Governance and Leadership The Public Health and Sanitation jointly with Medical Services subsector developed the following policy documents during the period under review: 19

1.8.2.8 Health Policy Framework (2012-2030); Under the review period, the health sector developed the National Health Policy Framework in line with the Constitution and Kenya Vision 2030. In addition, the sector has embarked on the development of a health law. 1.8.2.9 Health Sector Strategic Plan; The sector has also collaborated with relevant stakeholders to speed up the development of the National Health Strategic Plan III 2012/13-2016/17 in order to facilitate improved service delivery. 1.8.2.10 Position Paper on Devolution To respond to the implementation challenges of the new constitution, the Ministries of health developed a Position Paper. The position paper presents the health sectors position on key issues in relation to the implications of the constitution in the health sector. As more legal instruments implementing the Constitution come into effect, the Position Paper will continue to be reviewed and aligned to these Acts. 1.8.3 RESEARCH AND DEVELOPMENT SUB-SECTOR Research & Development has continued to contribute immensely to the overall achievement of National and international health goals. Key achievements within the period include tremendous increase in development partner grants. There are notable achievements in HIV prevention through multi-centre collaborative research that demonstrated use of ARVs as a method of prevention. The KEMRI scientists are also part of International group working on a promising malaria vaccine that has shown interim efficacy of over 50 percent in preventing malaria. 1.8.3.1 Scientific publications Within the period KEMRI has published and disseminated over 1000 publications in peer-reviewed journals that has contributed new knowledge for evidence-based policy formulation. 1.8.3.2 Outbreak investigations & emergency preparedness Through specialized services, KEMRI has been able to support effective outbreak investigation services regionally as well as locally for example ebola. 1.8.3.3 Research Translation- Policy formulation Technical staffs within KEMRI are an integral part of the Technical Working Groups in the sector for translation of research into evidence-based policies and practice guidelines. 20