is kenya’s health system ready for devolved governance?
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Is Kenya’s health system ready for
devolved governance?
Aaron MulakiHealth Systems/Public Administration Advisor
June 20, 2014
Context
Kenya recently celebrated its first birthday in a devolved system of governance following the March, 2012 elections under 2010 constitution
Devolution in Kenya not new. False start in 1963 under majimbo followed by failures in other decentralization reforms
Devolution is pursued for technical, political, and financial reasons
In Kenya devolution of power seeks to correct historical injustices associated with centralized governance
Kenya’s devolution framework considered complex in scale and magnitude
New constitution progressive in bill of rights
Why devolve?
Principles-Democracy, separation of power, reliable resources, gender (Art 175, CoK)
Objectives (Art 174) Promoting democratic and accountable exercise of power Fostering national unity by recognizing diversity Enable self governance to the people Enhance participation of the people in the exercise of the powers and the state making
decisions for them Recognize the right of communities to manage their own affairs and to further their
development Promote social and economic development and the provision of proximate, easily
accessible services Ensure equitable sharing of national and local resources Facilitate the decentralization of state organs, their functions and services Enhance checks and balances and separation of power
Kenya’s devolution framework
Numerous reforms implemented with mixed results (e.g DHMTs)
Devolving health will improve efficiency, stimulate innovation, improve access and equity, and promote accountability and transparency
Schedule IV assigns policy, national referral facilities, capacity building to national government and service delivery to counties
Devolving health has had its fair share of challenges
Success on uptake of health function by counties is largely dependent on health system preparedness
Decentralization of health not new!
Assessing county health system readiness
Overview of Methodology
Examined variations in county revenue per capita
Assessed availability of health facilities
Assessment of 16 county level health input indicators based on the WHO building blocks under four categories;
Physical infrastructure and equipment; human resources for health; drug availability, organization of service delivery and governance
Data sources included: SARAM-Kenya Service Availability and Readiness Assessment Mapping (SARAM), a
census involving all health facilities in the country and management units Pets-Plus- a combination of Public Expenditure Tracking Survey and a Service
Delivery Indicator (SDI) survey that assesses overall service delivery performance of 294 public and nonprofit private health facilities and 1,859 health providers in Kenya
How was county health system readiness analyzed?
Results
Availability of health facilities
There is inequality in health facility distribution across 47 counties
Counties must make sure that their clients spend little time accessing a facility, and facilities must be able to handle as many case loads
• Half of counties have fewer than 2 health facilities per 10,000 people and 4.2 facilities per 100 square kilometers
• Mombasa and Nairobi have 134 and 124 per 100 sq kms, but have far fewer facilities per 10,000 (2.9 and 2,4 respectively)
• Bungoma and Busia have fewest facilities per 10,000 people but more facilities per 100 sq kilometers
• Kilifi, Mandera,Turkana, Wajir, Narok and Bomet have low number of facilities per 10,000 and low number of facilities per 100 sq kms
Performance on infrastructure and equipment poor
1. Percentage of primary care centers with an ante-natal(ANC) ward• Huge variations (8-85%)
2. Number of operating theatres per hospital• 0.09 to 2.33
3. Number of ambulances per hospital• 0.06 to 3.636
4. Number of KEPI refrigerators per maternal and child health unit• 1.13 to 3.87
5. Number of CD4 machines per facility with laboratories• 0 to 0.58
• Samburu is the only county that is in the top third for at least 4/5 indicators
• Isiolo, Narok, Kericho, Elgeyo Marakwet and Bungoma are the only counties that do not fall in the bottom third in any of the indicators
• Kirinyaga,Wajir, Kajiado consistently in the bottom third of all counties across all the indicators
Equipment/Infrastructure Availability
Human Resources for Health
Doctors per 10,000 people in the 47 counties ranges from (0) Mandera to (2) Nairobi benchmark is 3(MOH,2013b)
Higher densities for nurses between 0.9 per 10,000 (Mandera) to 11.8 per 10,000 (Isiolo)
Only 4 counties meet Kenya’s benchmark of 8.7 per 10,000.
Staff absenteeism• W.Pokot, Makueni have lowest
rates < 20% • Nyamira, Siaya, Transzoia,
Uasin Gishu >40%
Diagnostic Capacity• Makueni, Nairobi, Mombasa
>80% • Homabay, Kitui, Uasin Gishu,
Kilifi
Quantities Quality
Availability of drugs
• 34-63% of counties have maternal health tracer drugs but 18-39% of child health tracer drugs available
• Large disparities in the availability of first line HIV drugs (0-50%)
• Kisumu, Kisii, Vihiga, and Siaya consistently top third in drug availability
• Transzoia, E-Marakwet, Nandi, Nyeri & T.River bottom
1. 11 maternal health tracer drugs2. 11 child health tracer drugs3. First-line drugs for HIV4. ACT, first line treatment for
malaria5. 4FDC, intensive treatment for
tuberculosis 6. Metformin, preferred OGLA
treatment for diabetes
Drug types Average availability
Revenue per capita (RPC) ranges significantly by county. Mandera has 6 times the per capita of Nairobi
RPC sometimes corresponds to counties’ performance across the 16 indicators e.g Nairobi has the least RPC and is in the bottom third of counties for 9/16 indicators. Machakos, Narok, Nakuru, Kericho, Siaya, Kakamega & Makueni
with below average RPC preform better than other counties Counties with above average RPC that are in the bottom third for
at least 8/16 indicators
RPC not necessarily linked to county health system readiness
County readiness and Revenue
Conclusion and Recommendations
1. Focus on relatively low-performing counties 2. Target weak areas across all counties3. Provide counties with norms and standards for benchmarking
• There is great variability in county health system readiness • About nine counties preform consistently poorly-bottom third across
the 16 indicators• Counties that performed relatively well across the indicators may still
have inadequate inputs
www.healthpolicyproject.com
Thank You!
The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with CEDPA (CEDPA is now a part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA).
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