analysis of fiscal space and policy options for targeted … · · 2015-01-16expenditure...
Post on 26-Apr-2018
213 Views
Preview:
TRANSCRIPT
HEALTH SECTOR EXPENDITURE
INDICATORS & BENCHMARKS
KENYA
Bernadette Wanjala Kenya Institute for Public Policy Research and Analysis (KIPPRA)
10TH DECEMBER 2014
MONTREUX, SWITZERLAND
MACROECONOMIC CONTEXT
Economy growing at 5.7% after rebasing (up from 4.7%
before rebasing)
After rebasing, country moved to lower middle income
country GDP per capita of US$ 1,246 (up from US$ 994
before rebasing)
Mounting expenditure pressures against revenue
shortfalls (only income tax meeting the targets)
In 2013: tax to GDP = 19.3% (24% before rebasing);
expenditure to GDP was 29.5% (37% before rebasing)
Debt to GDP in 2013 = 36% (45% before rebasing)
Health spending in total expenditure at national level –
6% in 2012/13 and 2% in 2013/14 (after devolution) –
Far from the Abuja declaration benchmark.
WHY FISCAL SPACE FOR HEALTH
Considerable achievements – under five mortality,
immunization. Big challenge of high disease burden (esp NCD) & deterioration of maternal mortality ratio - 414 in 2003 to 488 deaths per 100,000 live births in 2008-09
Low access to health services - 52 percent based on the 5km radius norm. Also wide regional disparities.
Low public per capita funding - public per capita spending at $19.2; per capita health spending still remains low at $42 compared to the WHO recommendation of $54 per capita.
Substantial funding by donors esp for HIV AIDS, malaria and TB e.g. 90% of funding for ARVs. Some largely off-budget
Empirical evidence shows higher levels of health expenditure associated with better performance on the health-related MDG indicators
Devolution of health – some health functions transferred to county governments e.g. primary health care and county health facilities and pharmacies
EMPIRICAL EVIDENCE SHOWS HIGHER LEVELS OF HEALTH
EXPENDITURE ARE ASSOCIATED WITH BETTER
PERFORMANCE ON THE HEALTH-RELATED MDG INDICATORS
HEALTH SECTOR FINANCING
Source (KShs Mn) 2001/02 2005/06 2009/10
Public 24,341 29,879 35,382
Private 44,405 40,077 45,087
Donors 13,486 31,613 42,384
Others 82 408 0
Total 82,314 101,978 122,854
Percentage contributions
Public 29.6 29.3 28.8
Private 53.9 39.3 36.7
Donors 16.4 31 34.5
Others 0.1 0.4 0
Total 100 100 100
WHO PAYS FOR HEALTH? NEED TO INCREASE
PUBLIC SPENDING ON HEALTH
0%
10%
20%
30%
40%
50%
60%
70%
80%
Kenya Liberia Sierra Leone Tanzania Uganda
37%
18%
75%
32%
48%
29% 32%
18%
40%
26%
34%
50%
7%
28% 26%
Sh
are i
n t
ota
l sp
en
din
g
Private Government Other
HEALTH SECTOR FINANCING UNDER DEVOLUTION IN
KENYA
Total transfers to counties in 2013/14 – 210 billion
(KShs. 190b equitable share & 20b conditional
transfers)
20% of total revenue
13 % of government expenditure
In addition to equitable transfers, county govts can
raise additional revenue thro licenses and fees,
property taxes.
Implication of devolution on health service delivery?
At national level, risk of having sent too much to the
counties; for health in 2013/14, 51%
Over-reliance on donor funding for some line items –
HIV, TB & malaria – no established coordination
framework for counties
COST OF DEVOLVED FUNCTIONS
Health spending accounted for 25 - 30% of total cost of
devolved functions
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Actual Actual Budget Ceiling Projection Projection
Agriculture & Rural development 10.5 11.2 9.8 14.9 15.7 16.5
Education 0.4 0.4 1.6 1 1.1 1.1
Energy, Infrastructure and ICT 45.7 53.5 67.6 77 80.9 84.8
Environment, Water &
Sanitation 8 8.8 5.8 10.9 11.4 12
General Economic, Commercial,
Labour Affairs 8.7 6 4.9 9.7 10.2 10.7
Governance, Justice, Law &
Order 0.3 0.3 0.5 0.5 0.6 0.6
Health 21.8 31.4 53.9 47.7 50.2 52.5
Public Administration &
International relations 14.9 17.6 22.3 25.3 26.6 27.8
Social Protection, Culture &
Recreation 6.2 10.1 7.7 11.2 11.8 12.4
Total 116.5 139.3 174.1 198.2 208.5 218.4
HEALTH SECTOR FINANCING UNDER DEVOLUTION
Health budget lumped together for equitable sharing
by counties - Budgetary priorities set by county govts
2012/13 2013/14 2014/15 2015/16
2013
MTEF
Budget Medium Term estimates Total
National 33.1 45.5 47.1 46.7 139.2
Of which transfer to
public entities 15.7 17.3 18.7 19.2 55.1
Counties 53.9 47.7 50.2 52.5 150.4
Total 87.0 93.2 97.3 99.2 289.6
COUNTY ALLOCATIONS TO HEALTH 2013/14 (KSHS.
BILLION) While health spending accounted for 25 -
30% of total cost of devolved functions,
how much is allocated by counties?
Level of
funding for
health
varied
across
counties –
no
guidelines
on minimum
allocations
because of
autonomy by
county
governments
-
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Kir
inyaga
Bom
et
Kaji
ad
o
Isio
lo
Sia
ya
Mu
ran
g'a
Nyam
ira
Tait
a/T
aveta
Meru
Nan
di
Naro
k
Mars
abit
Waji
r
Elg
eyo/M
ara
kw
et
Mach
ak
os
Hom
a B
ay
Tra
ns
Nzoia
Kit
ui
Kil
ifi
Kw
ale
Kis
um
u
Kia
mbu
Nak
uru
Tu
rkan
a
ACTUAL TO BUDGETED HEALTH EXPENDITURE
RATIOS 2013/14
Actual spending on health quite low – only 3 counties over 100% ratio of actual/budgeted
16 counties below 50% ratio
Initial allocation of about 37% of total county expenditure
Low actual expenditure due to ambitious targets (both expenditure and revenue)
0%
50%
100%
150%
200%
250%
300%B
usia
Mu
ran
g'a
Tu
rkan
a
Bu
ngom
a
Kak
am
ega
Lam
u
Kir
inyaga
Gari
ssa
Keri
cho
Mach
ak
os
Elg
eyo/M
ara
kw
et
Nyam
ira
Kis
ii
Nak
uru
Kil
ifi
Waji
r
Vih
iga
Nan
di
Th
ara
ka -
Nit
hi
Uasi
n G
ish
u
Isio
lo
Bom
et
Nair
ob
i C
ity
Meru
PROPORTION OF ACTUAL HEALTH SPENDING IN TOTAL
EXPENDITURE BY COUNTY
Proportion of health in total costing of health devolved functions was about 25 – 30%; compared to an average actual of 23%
Only 8 counties have over 20%
22 counties have =< 10%
Cumulative national + county = 4% in 2013 compared to 6% pre-devolution
Likely underfunding of health
0%
5%
10%
15%
20%
25%
30%
Bu
sia
Em
bu
Man
dera
Kir
inyaga
Keri
cho
Sia
ya
Kis
ii
Kak
am
ega
Bom
et
Nyam
ira
Bu
ngom
a
Lam
u
Tu
rkan
a
Isio
lo
Hom
a B
ay
Kw
ale
Uasi
n G
ish
u
Kil
ifi
Kis
um
u
Nak
uru
Tait
a/T
aveta
Th
ara
ka -
Nit
hi
Meru
Ba
rin
go
Avg Actual Health Exp to total
Exp = 23%
HEALTH NEEDS VIS A VIS HEALTH EXPENDITURE BY COUNTIES
Overall morbidity Full immunization
Health sector expenditure to total expenditure ratio
≤10% 11% - 20% 21% - 30%
Ove
rall
Mo
rbid
ity
10% - 20% 8 counties 7 counties 1 county
21% - 30% 6 counties 8 counties 2 counties
31% - 50% 7 counties 4 counties 3 counties
Health sector expenditure to total expenditure ratio
≤10% 11% - 20% 21% - 30%
Fully
imm
un
ized
po
pu
lati
on
30% - 50% 6 counties 1 county 2 counties
51% - 70% 7 counties 10 counties 4 counties
>70% 8 counties 8 counties none
CONCLUSION
Health sector likely to be under-funded at county level
given the varied levels of funding
National + county spending on health = 4%; lower than
pre-devolution level
At county level, need for in-depth review of county
budgets to determine level of funding for health vis-à-
vis health needs – will require creation of additional
fiscal space for health
Possibility of guidelines for budgetary allocations? Set
benchmarks for minimum allocations to key devolved
functions such as health.
Possibility of conditional grants for specific line items,
especially malaria, TB and HIV AIDS that were largely
donor financed.
THANK YOU
ASANTE
top related