Republic of Kenya

Ministry of Health

PublicPublic ExpenditureExpenditure ReviewReview 20072007

Printed on: 09 January 2018 Contents

Contents...... i Abbreviations...... iv 1 Background...... 1 1.1 Overall objective of the PER...... 1 1.2 Objectives of the Ministry’s PER...... 1 1.3 Health Status Indicators...... 2 1.4 The Health Services Delivery System...... 2 1.5 Linkage between ERS, NHSSPII...... 4 1.6 NHSSP II - Key principles of AOP2...... 5 1.7 Strategic issues and policies of the ministry...... 6 1.7.1 Flow of funds to rural health facilities...... 6 1.7.2 Guidelines to financial flow to health centres and dispensaries...... 8 1.7.3 Procurement position paper...... 8 1.8 MoH Collaboration with the Faith based organisations...... 10 1.8.1 Current collaboration with FBOs...... 12 1.8.2 Progress report on MOH/FBHS - TWG on partnership policy Development...... 12 1.8.3 Immediate re-instatement of financial grant to church Health facilities 13 1.8.4 Support in kind through Drugs, Medical Supplies Equipment and Ambulances...... 14 1.8.5 Legal Policy Framework...... 14 1.8.6 Donor support to the Health Sector...... 15 1.9 The Scope and Organization of this Public Expenditure Review...... 15 1.10 The Ministry’s Mission Statement and Core activities...... 16 1.10.1 Kenyatta National Hospital...... 16 1.10.1.1 Financing...... 18 1.10.1.2 Impact of Poverty on the hospital...... 19 1.10.2 Kenya Medical Research Institute (KEMRI)...... 20 1.10.2.1 Achievements...... 20 1.10.3 National Health Insurance Fund...... 21 1.10.3.1 Financing Hospitals...... 22 1.10.4 Kenya Medical Training College (KMTC)...... 22 1.10.5 Kenya Medical Supplies Agency (KEMSA)...... 23 1.10.6 Moi Teaching and Referral Hospital...... 24 1.10.7 Increasing Access...... 25

i 2 Government Spending on Health through the MoH...... 25 2.1 Public Spending on Health: Context...... 25 2.2 Government Spending on Health: Aggregate Levels and Trends...... 26 2.2.1 Total Spending on Health...... 26 2.2.2 Recurrent and Development Expenditure...... 27 2.2.2.1 Ministry of Health Recurrent Expenditure by Economic Category 27 2.2.2.2 Ministry of Health Expenditure (Actual) by sub Vote...... 28 2.2.3 Budget Implementation Actual Expenditures versus Approved Budgets 31 2.2.4 Appropriations in Aid (AiA) and Cost Sharing ( )...... 37 2.2.5 Appropriations in Aid (AiA)...... 37 2.2.5 Cost Sharing...... 38 Table 2.2.7 Total reported revenue collection by province and financial year (KSh million)...... 39 3 3. Review of Projects/Programs related to the Ministry...... 40 3.1 Core poverty programs...... 40 Table 3.1Summary of projects/programmes in the Ministry, 2003/04- 2006/07...... 40 3.2 Output/Outcomes related to expenditures...... 41 3.3 Ministry’s On-going Projects...... 41 3.4 Stalled Projects...... 46 3.5 New projects TO BE INITIATED IN 2006/07 CHAO TO PROVIDE INFORMATION-CHERUYOIT TO FOLLOW UP – NO NEW PROJECTS SO FAR...... 47 3.6 Weaknesses in project implementation – Cheruiyot to refer to notes attached to pending bills 05/06...... 47 4 Pending Bills...... 47 5 Analysis of Ministry outputs and corresponding performance indicators...... 49 5.1 Output targets...... 49 5.2 Overview of Sector Performance Indicators and Targets...... 50 5.3 Links Budget allocation to Output Delivery...... 51 5.4 Expected Outputs and Outcomes 2006/07...... 52 5.4.1 Human Resource...... 52 5.4.2 Drug Procurement...... 52 5.4.3 Access to ARVs...... 52 5.4.4 Restructuring of the Ministry...... 53

ii 5.4.5 Restructuring of Parastatals...... 53 6 Public Expenditure Management (PEM)...... 53 6.1 Budget Preparation Process...... 54 6.2 Results-Oriented Public Expenditure Management...... 55 6.2.1 Results-Based Management...... 56 7 Human Resources Development and Capacity Building...... 56 7.1 Service Delivery Inputs...... 57 7.2 Human resources situation...... 58 7.3 Human resource disparities...... 59 7.4 Impact of HIV/AIDS on Human Resources...... 62 8 Implementation of Recommendations of the 2006 PER...... 62 8.1 Action plans for implementation of 2006 MPER...... 62 8.2 Activities and Supporting Actions...... 64 8.3 Timeframes and targets...... 64 9 Challenges and Constraints...... 65 9.1 Integrating NHSSP II and AOPs into the Annual Budget...... 65 9.2 Reviewing Targets...... 66 10 Conclusions and Key Recommendations...... 67 11 Annexes...... 70 CHERIYOT TO VERIFY- NAMES, % COMPLEION, COST OF COMPLETION (Mr. Gitonga)...... 70 Annex 1: Inventory Of Stalled Building Construction Projects – D11-Ministry Of Health- CHERIYOT TO VERIFY...... 70 12 References...... 72

Abbreviations

Description AIDS Acquired Immune Deficiency Syndrome CBS Central Bureau of Statistics GDP Gross Domestic Product

iii HIV Human Immunodeficiency Virus

MDG Millennium Development Goals

MoH Ministry of Health 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 Faith Based Organizations PRSP Poverty Reduction Strategy Paper SARS Severe Acute Respiratory Syndrome HLA Human leukocyte Antigen

iv 1 Background

1.1 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 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 6.71 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 system2 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 Excludes the northern part of the country 2 See the NHSSP II

/2 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  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  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  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 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 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 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 KEC- CHAK CHAK/KCS CS Hospital 147 44 24 68 Health centres 460 92 47 139 Dispensaries 1,630 281 311 592 TOTAL 2,237 417 382 799

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 introduction of 10/20 policy on July 1st 2004, which set a standard fee of KSh 10

4 Ministry Of Health: RHF Unit Cost/Cost Sharing Review Study & The Impact Of The 10:20 Policy, 2005.

/9 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 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 12th 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 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:

. 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;

/12 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 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;  Competitive advantage;

/14  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.

Figure 1 .1 : In patient and Out patient workload

800 ) 0 0 0

s t 400 n e i t a

o 0 N 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5

Outpatient Inpatients

/15 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 2000/01 1,754.2 1,349.6 534.8 1,884.5 2001/02 5,283.9 1,865.2 807.1 2,672.4 2002/03 5,289.7 2,327.0 596.5 2,923.5 3,400.4 2003/04 5,788.0 2,448.0 952.4 2,659.0 2004/05 9,733.4 917.2 3,576.2 2005/06 1,852.1 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.

/16 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 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

/17 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.

 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.

/18 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.

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

5 Includes personnel and other admin expenses

/19 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%.

/20 Table: Growth of members’ contributions and reimbursements 2002/03 2003/04 2004/05 2005/06 REVENUES Contributions 2,523,876,081 2,639,883,578 3,117,241,202 3,458,847,816 Other income6 210,992,974 72,358,041 157,349,232 188,463,585 TOTAL REVENUES 2,734,869,055 2,712,241,619 3,274,590,433 3,647,311,401

EXPENDITURE Reimbursements 822,014,878 713,297,431 685,490,051 1,105,875,734 Administration 1. Personnel 776,263,163 827,258,377 1,040,765,820 1,030,516,535 2. Other 846,506,931 704,478,176 538,018,321 496,191,147 admin Total admin 1,622,770,094 1,531,736,553 1,578,784,141 1,526,707,682 expenses TOTAL EXPENDITURE 2,444,828,033 2,245,033,984 2,264,274,192 2,632,583,416 Reimbursements as % of 30 26 21 30 total revenue Total admin as a % of 59.34 56.47 48.21 41.86 total revenue

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 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 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 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 2 Government Spending on Health through the MoH 2.1 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 Table 2.2: Ministry of Health Actual Expenditure (Gross) KSh million 2001/022002/032003/042004/052005/06 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 0.8 7.1 16.5 20.1 Per Capita KSh 488.44 481.97 506.05 578.28 681.78 Per Capita $ 6.28 6.29 6.52 7.48 9.47 Ministry of Health Expenditure (Gross) as % of Total Government1 Recurrent 8.23 8.69 7.76 7.66 6.29 Development 17.18 5.12 2.77 2.01 3.73 Total 9.01 8.33 6.99 6.1 5.73 Ministry of Health Expenditure (Gross) as % of GDP Recurrent 1.38 1.4 1.41 1.41 1.29 Development 0.27 0.09 0.09 0.14 0.21 Total 1.65 1.49 1.51 1.55 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.

/26 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

Table 2.3 Recurrent (gross) Expenditure by Economic Category KSh millions

2000/01 2001/02 2002/03 2003/04 2004/05 2005/06

Actual Actual Actual Actual Actual Actual Total Recurrent (Gross) 11,040.8 12,714.9 14,405.4 15,438.5 17,417.4 19,765.1 Salaries and Other Personnel 5,251.8 6,639.9 7,798.1 8,100.8 9,034.9 10,407.3 as % Total Recurrent 47.6 52.2 54.1 52.5 51.9 52.7 Transfers, Subsidies and Grants 848.1 1,027.7 1,157.2 1,454.7 1,562.5 1,634.9 as % Total Recurrent 7.7 8.1 8.0 9.4 9.0 8.3 Drugs and Medical Consumables 1,680.8 1,476.8 1,349.7 1,716.0 1,866.2 2,074.2 as % Total Recurrent 15.2 11.6 9.4 11.1 10.7 10.5 Other Operations & Maintenance 1,749.9 1,324.0 1,257.4 1,285.2 1,756.0 1,481.0 as % Total Recurrent 15.8 10.4 8.7 8.3 10.1 7.5 Purchase of Plant & Equipment 160.6 29.0 94.5 14.6 80.7 595.6 as % Total Recurrent 1.5 0.2 0.7 0.1 0.5 3.0 Kenyatta National Hospital 1,349.6 1,865.2 2,327.0 2,409.0 2,659.0 2,858.0 as % Total Recurrent 12.2 14.7 16.2 15.6 15.3 14.5 Moi Referral Hospital 0.0 352.3 421.5 458.1 458.1 714.1 as % Total Recurrent 0.0 2.8 2.9 3.0 2.6 3.6

2.2.2.2 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 Actual Actual Actual Actual Actual General Admin. And 110Planning 700.7 587.0 714.8 760.4 1,223.0 912.527

Total as % Total MoH 6.3 4.6 5.0 4.9 7.0 4.6 111Curative Health 6,080.9 6,758.6 7,677.6 7,768.0 8,639.5 9996.759

Total as % Total MoH 55.1 53.2 53.3 50.3 49.6 50.6 112Preventive and Promotive 874.4 665.2 632.2 863.6 795.9 756.995

Total as % Total MoH 7.9 5.2 4.4 5.6 4.6 3.8 113Rural Health Services 1,121.4 1,378.1 1,436.4 1,687.6 2,041.5 2881.656

Total as % Total MoH 10.2 10.8 10.0 10.9 11.7 14.6 Health Training and 114Research 884.2 1,060.2 1,161.8 1,459.8 1,467.7 1511.916

Total as % Total MoH 8.0 8.3 8.1 9.5 8.4 7.6 Medical Supplies Coord 116Unit 29.6 48.3 34.2 32.0 132.6 133.177

Total as % Total MoH 0.3 0.4 0.2 0.2 0.8 0.7 Kenyatta National 117Hospital 1,349.6 1,865.2 2,327.0 2,409.0 2,659.0 2858.014

Total as % Total MoH 12.2 14.7 16.2 15.6 15.3 14.5 Moi Teaching and 118Referral 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 3.6 19, Total MoH 11,040.8 12,714.9 14,405.4 15,438.5 17,417.4 765.1

Total as % Total MoH 100.0 100.0 100.0 100.0 100.0 100.0

/28 Table 2.5: Ministry of Health: Development Expenditures (gross) by Sub Vote KSh Millions.

Code Sub-Vote 2000/2001 2001/2002 2002/2003 2003/2004 2004/05 2005/06 Actual Actual Actual Actual Actual Actual General Admin. 110 and Planning 16.9 1,193.2 432.5 196.9 158.7 357.213 Total as % Total 9. 1 MoH 1.6 47.4 45.8 19.6 1 1.0 111 Curative Health 98.0 637.2 120.1 206.5 162.0 702.779 Total as % Total 9. 2 MoH 9.5 25.3 12.7 20.6 3 1.7 Preventive and 112 Promotive 386.2 134.0 183.4 87.9 934.0 1162.316 Total as % Total 53. 3 MoH 37.4 5.3 19.4 8.8 6 5.9 Rural Health 113 Services 248.8 397.7 198.4 446.1 466.2 913.5 Total as % Total 26. 2 MoH 24.1 15.8 21.0 44.5 8 8.2 Health Training 114 and Research 281.6 157.3 10.9 65.6 20.0 56 Total as % Total MoH 27.3 6.2 1.2 6.5 1.1 1.7 Medical Supplies 116 Coord Unit 0.0 0.0 0.0 0.0 - 50 Total as % Total MoH 0.0 0.0 0.0 0.0 - 1.5 Kenyatta National 117 Hospital 0.0 0.0 0.0 0.0 - 0 Total as % Total MoH 0.0 0.0 0.0 0.0 - - Moi Teaching and 118 Referral 0.0 0.0 0.0 0.0 - 0 Total as % Total MoH 0.0 0.0 0.0 0.0 - - 1,741. 3,2 Total MoH 1,031.5 2,519.4 945.3 1,003.0 0 41.9 Total as % Total 100. 10 MoH 100.0 100.0 100.0 100.0 0 0.0

/29 Table 2.6: Ministry of Health Total Expenditures (gross) by Sub Vote KSh Millions

CodeSub-Vote 2000/2001 2001/2002 2002/2003 2003/2004 2004/05 2005/06 Actual Actual Actual Actual Actual Actual General Admin. and 1,38 1 110 Planning 717.6 1,780.2 1,147.3 957.3 1.7 ,269.7 Total as % Total MoH 5.9 11.7 7.5 5.8 7.2 5.5 8,8 10 111 Curative Health 6,178.9 7,395.8 7,797.7 7,974.5 01.6 ,699.5 Total as % Total 4 MoH 51.2 48.5 50.8 48.5 5.9 46.5 Preventive and 1,73 1 112 Promotive 1,260.6 799.2 815.6 951.5 0.0 ,919.3 Total as % Total MoH 10.4 5.2 5.3 5.8 9.0 8.3 2,5 113 Rural Health Services 1,370.2 1,775.8 1,634.8 2,133.7 07.7 3,795.2 Total as % Total 1 MoH 11.3 11.7 10.6 13.0 3.1 16.5 Health Training and 1,48 1 114 Research 1,165.8 1,217.5 1,172.7 1,525.4 7.7 ,567.9 Total as % Total MoH 9.7 8.0 7.6 9.3 7.8 6.8 Medical Supplies 13 116 Coord Unit 29.6 48.3 34.2 32.0 2.6 183.2 Total as % Total MoH 0.2 0.3 0.2 0.2 0.7 0.8 Kenyatta National 2,6 117 Hospital 1,349.6 1,865.2 2,327.0 2,409.0 59.0 2,858.0 Total as % Total 1 MoH 11.2 12.2 15.2 14.7 3.9 12.4 Moi Teaching and 45 118 Referral 0.0 352.3 421.5 458.1 8.1 714.1 Total as % Total MoH 0.0 2.3 2.7 2.8 2.4 3.1 19,15 2 Total MoH 12,072.3 15,234.3 15,350.7 16,441.5 8.3 3,007.0 Total as % Total 10 MoH 100.0 100.0 100.0 100.0 0.0 100.0

2.2.3 Budget Implementation Actual Expenditures versus Approved Budgets

Table 2.7 shows the comparison between approved and actual recurrent and development expenditures by sub vote. While the approved budgets may

/30 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 PrintedApprovedPrintedApprovedPrintedApprovedPrintedApprovedPrintedApprovedPrintedApproved Code Sub-Vote Recurrent General Admin. and 110Planning 193 137 141 135 137 132 157 141 135 97 88 84

/31 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 PrintedApprovedPrintedApprovedPrintedApprovedPrintedApprovedPrintedApprovedPrintedApproved Code Sub-Vote Curative 111Health 153 100 180 154 159 152 152 152 177 99 100 98 Preventive and 112Promotive 176 158 129 126 112 94 86 86 103 94 75 74 Rural Health 113Services 36 35 39 34 33 33 33 34 44 102 96 96 Health Training and 114Research 115 103 137 101 109 100 100 100 101 100 101 100 Medical Supplies Coord 116Unit 70 87 106 83 52 50 46 46 79 98 97 97 Kenyatta National 117Hospital 100 100 142 100 126 105 100 100 100 100 100 100 Moi Teaching 118and Referral 267 100 121 100 109 100 100 100 100 100 Total 111 105 121 100 106 100 96 97 109 99 98 96

Development General Admin. and 110Planning 11 23 158 95 50 43 25 32 27 57 35 51 Curative 111Health 11 22 75 107 14 23 26 60 23 38 46 41 Preventive and 112Promotive 29 39 29 47 24 20 5 8 27 39 27 24 Rural Health 113Services 20 25 27 27 10 9 30 25 26 43 38 47 Health Training and 114Research 92 99 100 5 5 21 46 2 7 10 9 Medical Supplies Coord 116Unit Kenyatta National 117Hospital Moi Teaching 118and Referral Total 26 37 71 67 20 19 20 26 22 39 33 33 Combined General Admin. and 110Planning 140 123 152 105 82 74 76 83 92 90 62 71 Curative 111Health 131 140 160 148 137 140 135 146 157 96 93 90 Preventive and 112Promotive 69 82 82 98 62 51 35 47 41 54 36 33 Rural Health 113Services 32 32 35 32 26 25 32 32 39 81 71 77

/32 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 PrintedApprovedPrintedApprovedPrintedApprovedPrintedApprovedPrintedApprovedPrintedApproved Code Sub-Vote Health Training and 114Research 108 102 158 101 92 85 86 95 58 85 76 74 Medical Supplies Coord 116Unit 70 87 106 83 52 50 46 46 42 91 57 60 Kenyatta National 117Hospital 99 100 141 100 126 105 100 100 100 100 100 100 Moi Teaching 118and Referral 267 100 121 100 109 100 100 100 100 100 Total 87 91 108 92 84 79 78 83 81 87 76 76

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 Figure 2.6: Actual expenditure as % of Approved Recurrent budget by sub vote 180

100 % 80

0 2001/2002 2002/2003 2003/2004 2004/05 2005/06

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 Economic Categories2001/20022001/20022002/20032002/20032003/20042003/20042004/05 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 ApprovedPrintedApproved

Total Recurrent (Gross) 121 100 106 100 96 97 109 99 98 96.30 Salaries and Other Personnel 121 97 102 100 98 100 122 101 102 100.24 Transfers, Subsidies and Grants 135 98 108 100 100 100 98 98 100 99.69 Drugs and Medical Consumables 87 99 93 92 80 80 94 94 83 90.17 Other Operations & Maintenance 121 120 108 98 102 95 99 99 90 74.09 Purchase of Plant & Equipment 85 80 99 98 73 74 95 95 86 94.52 Kenyatta National Hospital 142 100 126 105 100 100 100 100 100 100.00 Moi Referral Hospital 267 100 121 100 109 100 100 100 100 100.00

Figure 2.7: Ac tual as share ofApproved 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 2001/20022001/20022002/20032002/20032003/20042003/2004 2004/200 2004/200 2005/062005/06 5 5

/35 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 PrintedApproved General Administration 148 146 165 154 164 171 217.3 103.3 88.4 85.6 and Planning Curative Health 209 169 179 170 171 172 208.6 100.0 106.1 103.6 Preventive and 177 163 132 121 114 115 116.7 93.9 71.8 74.9 Promotive Rural Health Services 18 14 14 15 16 16 19.7 112.3 92.0 91.1 Health Training and 123 110 119 115 101 102 127.0 113.1 122.7 113.8 Research Medical Supplies 80 73 30 28 23 23 24.7 85.6 77.5 74.2 Coordinating Unit Total 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 2002/032003/042004/05 2005/06 General Administration and 141 146 154 171 103.3 85.6 Planning Curative Health 181 169 170 172 100.0 103.6 Preventive and 270 163 121 115 93.9 74.9 Promotive Rural Health 13 14 15 16 112.3 91.1 Services Health Training 117 110 115 102 113.1 113.8 and Research Medical Supplies 50 73 28 23 85.6 74.2 Coordinator Unit Total 101 97 100 100 100.8 100.2

/36 Fig ur e 2.8: W ag e s and Salar ies: A ctual as shar e o f A ppr o v ed Bud g e t

0 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06

General Admin. and Planning Curative Health Preventive and Promotive Rural Health Services Health Training and Research Medical Supplies Coord Unit Total

2.2.4 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 1,277.5 485.0 328.1 252.9 505 314.3 532.1 TOTAL 227.2 1,343.8 575.0 385.2

/37 2.2.6 Appropriations in Aid (AiA) 2001/022001/02 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 PrintedApprovedPrinted ApprovedPrinted ApprovedPrintedApprovedPrintedApproved

Total Recurrent 158 156 199 100 113 111 101 100 39 39 Total Developmen t 53 47 16 13 10 14 6 12 15 11 TOTAL 55 49 18 15 12 16 8 15 16 12

fig 2.9Actual as share of Approved

600 % 400

0 2000/2001 2001/2002 2002/2003 2003/2004 2004/05 2005/06 -200

Total Rec urrent Total Development TOTAL

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 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 Review of Projects/Programs related to the Ministry 3.1 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 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, 2003/04- 2006/07 Project Year Year of Total Total Estimated cost Actual Allocation Proposed Name & started completion Estimated cumulative of completion expenditure 2006/07 allocation category Project cost expenditure 2005/06 2007/08 up-to 2005/06 National Aids Yearly Continuous 9,609,115 9,125,563 483,552 9,125,563 10,684,547 11,401955 Control Programme Sexually Yearly Continuous 6,768,183 6,234,085.85 534,097.15 6,234,085.85 - - transmitted Infection District 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 Hospitals

Mental Health Yearly Continuous 135,427,831 127,476,542 8,051,289 127,476,542 82,776,738 84,571,083 Services Spinal Injury Yearly Continuous 13,301,061 13,199,514 101,547 13,199,514 12,134,443 12,552,080 Hospitals Rural Health Yearly Continuous 2,176,117,141 2,160,735,680 15,381,46 2,160,735,680 3,588,338,473 4,937,453,015 Centres and 1 Dispensaries Health 2001 2006 681,500,000 development Project (DARE)) Establishment 20005 20006 20,000,000 22,000,000 22,000,000 & equipping for parasite center (KEMRI) Environmental Yearly Continuous 49,473,960 42,800,554 6,673,406 42,800,554 163,361807 222,0555,903 Health Services Communicable 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 & Vector borne Diseases Nutrition Yearly Continuous 4,661,174 3,958,733.75 702,440.25 3,958,733.75 4,669,173 5,088,932 Programme Vector borne 2000 2006 11,477,511 10,781,196 696,315 10,781,196 - - Diseases control Family Yearly Continuous 46,875,193 45,669,477.90 1,205,715.10 45,669,477.90 46875192 49,918,562 Planning Maternal &CHC Rural Health Yearly Continuous 43,672,013 42,305,246 1,366,767 42,305,246 43,680,732 52,569,087 Training & Demonstration Centres Drugs Control Yearly Continuous 1,516,091 67,347.10 1,448,743.90 67,347.10 1,448,898 1,447,696 Inspectorate KEPI Yearly Continuous 339,809,001 205,278,124.45 134,530,876.55 205,278,124.45 487,136,131 488,769,942 National Yearly Continuous 100,576,800 100,440,937.10 135,762.90 100,440,937.10 100,590,800 120,624,355 leprosy &Tuberculosis Kenya Medical 2004 Continuous 185,000,000 50,000,000 135,000000 50,000,000 - - Supplies Agency (KEMSA) Specialized 2005 Continuous 980,000,000 1,647,144,236 1,470,500,000

/40 Project Year Year of Total Total Estimated cost Actual Allocation Proposed Name & started completion Estimated cumulative of completion expenditure 2006/07 allocation category Project cost expenditure 2005/06 2007/08 up-to 2005/06 Global Fund Special Global 2005 Continuous 160,000,000 393,777,140 379,479,000 Fund TB Special Global 2005 Continuous 2,134,365,707 1,587,294,225 Fund Malaria 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 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 Indicator e District Rehabilitation Improve the Most health Rehabilitation Hospitals and capacity of all facilities i.e. repairs, Construction district rehabilitated, re-roofing, re- of facilities hospitals and improved to painting, infrastructure acceptable and fencing, etc in to deliver working identified quality health conditions. district services and Quality health hospitals strengthen services completed 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 All structures Centres and improvements health rural health in rural health Dispensaries and facilities in the centres and centres and rehabilitation country to dispensaries dispensaries of rural serve rural improved and rehabilitated facilities poor better rehabilitated and improved 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 Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom Indicator 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 Increased Development intervention to enabling decentralized immunization Project support environment organizational coverage (DARE) strategies to for structures and Increased better target decentralized management contraceptive public management systems prevalence, subsidies to of integrated operational to etc 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 Equipment in Medical situation of capacity of improve existing most hospitals Equipment medical district equipment in in better and equipment in hospitals to various district working existing offer hospitals condition hospitals appropriate Appropriate diagnosis and equipment therapeutic purchased and services delivered to district

/43 Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom Indicator e hospitals. Rehabilitation Improvement Improve All mortuaries New of Mortuaries and face- mortuary country-wide mortuaries lifting of all services all improved, erected mortuaries over the functioning and where they do country-wide country rehabilitated not exist. Environmental Health Reduce the Increased safe Construction Health Services, incidence of water and of Services sanitation, environmental sanitation demonstration vector control, related coverage facilities waste diseases Reduced vector (latrines, management, borne diseases domestic drinking water Improved human water supply) quality, physical, Disease housing biological and surveillance, improvement, social sanitary pollution environment inspection and control, and Improved law health sanitary enforcement promotion dwellings, eating and work places Mental Health Provision of To provide All structures Hospital Services mental health curative care and equipment buildings fully care services services in in the hospitals renovated to mentally Nairobi area, rehabilitated. Roads and sick patients and help Equip mentally fences at the Renovation decongest sick patients hospitals and KNH, and serve with skills for repaired rehabilitation the densely carpentry and Sewerage of Mathare populated general repairs system at the Psychiatric eastern of equipment. hospitals Hospital, and suburbs of Improve the overhauled. Gilgil mental Nairobi. health care Community hospital services for the health mentally sick workers patients. trained on mental health care Spinal Injury Operations and Improve and Deserving spinal Operational Hospital maintenance make injury patients requirements of individual accessible access health for the spinal injury affordable care services. hospitals such

/44 Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom Indicator e health health care Number of as chairs for facilities services for the patients seeking patients, population care at these drugs, etc in with spinal hospitals place. injury. increased. Sexually Reducing Reduce the risk STIs reduced Public Transmitted sexually of STI information Infection transmitted transmission by messages, and diseases providing education through preventive programmes research, services Drugs, clinical supplies, services to equipment to treat STDs. support treatment for STDs Communicable Is an Reduced IDRS expanded Districts and Vector integrated mortality, to cover up to trained in Borne disease disability and 80% of the emergency Diseases surveillance morbidity due districts nation- preparedness and response to wide and response. involving communicable Communication Most health disease diseases infrastructure facilities have preparedness such as case and response, telephone, radio information data calls, faxes, and on priority management email network diseases and initiated in all information districts. dissemination, laboratory support services, training and communication Nutrition Reduce Incidences of Prevalence rate Advocacy Programme prevalence of micro-nutrients of iodine, conducted iodine, deficiency vitamin A and IEC materials Vitamin A and related Iron deficiencies on micro- Iron diseases in reduced. nutrients deficiencies mothers and deficiency among children

/45 Table 3.3: Summary of programmes, goals, outputs and indicators Programme Description Goal/Objective Output/outcom Indicator e mothers and reduced children Food control Food safety Incidences of Improved Health Administration control, food borne sanitary hygiene services inspection and illness reduced dwellings, eating promotion licensing, and work places Law export Enhanced enforcement certification personal and Sanitary and law food hygiene inspections enforcement Disease surveillance

3.3 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 BADEA 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 9,254,640 GOK 10 Kapsabet D.H GOK 6,600,000.00 11 Nandi Hills D.H. GOK 3,350,000.00 12 Iten D.H. GOK 5,083,000.00 13 Kapenguria D. H 3,274,200.00 GOK

/46 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 35 GOK Londiani SDH 7,158,650.00 36 GOK Kericho District Hospital 2,500,000.00 37 GOK Kisumu District Hospital 5,960,000.00 38 GOK New Nyanza PGH 9,831,838.00 39 GOK Kombewa SDH 7,000,000.00 40 GOK Migori District Hospital 10,622,430.00 41 GOK Awendo SDH 1,500,000.00 42 GOK Rongo SDH 1,500,000.00 43 GOK Homa bay District hospital 5,000,000.00 44 GOK Siaya District Hospital 4,180,000.00 45 GOK Yala SDH 5,500,000.00 46 GOK Nyando DH 7,500,000.00 47 GOK Muhoroni SDH 500,000.00 48 GOK Ogembo D.H 8,604,050.00

/47 Table4.1: Ministry of Health's Ongoing Projects - 2005/06 Project KSh Source 49 GOK Bondo D.H. 7,628,200.00 50 GOK Madiany S.D.H. 4,200,000.00 51 GOK Rachuonyo DH 5,262,000.00 52 GOK Suba D.H 6,000,000.00 53 GOK Kuria D.H. 5,000,000.00 54 GOK Kisii D.H 2,000,000.00 55 GOK Keumbu SDH 3,800,000.00 56 GOK Nyamira DH 3,663,000.00 57 GOK Nyeri PGH 14,926,345.00 58 GOK Thika district Hospital 7,116,330.00 59 GOK Gatundu Hospital 4,000,000.00 60 GOK Muranga D.H 6,000,000.00 61 GOK Muriranjas SDH 3,560,000.00 62 GOK Karatina D.H 3,780,000.00 63 GOK Mukurweini SDH 3,880,000.00 64 GOK Othaya SDH 6,000,000.00 65 GOK Kiambu District Hospital 5,550,000.00 66 GOK Tigoni SDH 5,450,000.00 67 GOK Kerugoya District hospital 5,809,477.00 68 GOK Kimbimbi SDH 7,000,000.00 69 GOK Nyahururu District Hospital 7,378,210.00 70 GOK Olkalou SDH 2,000,000.00 71 GOK Maragua District Hospital 9,288,608.00 72 GOK Runyenjes SDH 6,000,000.00 73 GOK Embu PGH 5,406,360.00 74 GOK Nyambene D.H. 11,635,000.00 75 GOK Miathene SDH 4,000,000.00 76 GOK Chuka District hospital 6,514,600.00 77 GOK Magutuni SDH 4,000,000.00 79 GOK Meru Central District 8,752,600.00 80 GOK Githongo SDH 2,000,000.00 81 GOK Kanyakine SDH 2,580,000.00

/48 Table4.1: Ministry of Health's Ongoing Projects - 2005/06 Project KSh Source 82 GOK Isiolo District Hospital 3,800,000.00 83 GOK Marsabit District Hospital 5,152,000.00 84 GOK Moyale D. H 3,000,000.00 85 GOK Garbatula S.D.H. 4,975,000.00 86 GOK Tharaka District 8,240,000.00 87 GOK Kitui District Hospital 7,270,000.00 88 GOK SiakagoD.H. 6,200,000.00 89 GOK Ishiara SDH 2,000,000.00 90 GOK Makueni D.H 2,200,000.00 91 GOK Makindu SDH 6,500,000.00 92 GOK Machakos General Hospital 12,122,000.00 93 GOK Mbooni SDH 2,000,000.00 94 GOK Mwingi District Hospital 8,024,952.00 95 GOK Tseeikuru SDH 6,000,000.00 96 GOK Kakamega PGH 1,740,000.00 97 GOK Malava sub-district Hospital 2,009,170.00 98 GOK Lumakanda D Hopsital 8,873,400.00 99 GOK Mt. Elgon District Hospital 3,236,000.00 100 GOK Teso District Hospital 8,943,885.00 101 GOK Bungoma District Hospital 24,664,360.00 102 GOK Webuye SDH 4,500,000.00 103 GOK Port Victoria SDH 6,618,425.00 104 GOK Alupe SDH 1,500,000.00 105 GOK Vihiga District Hospital 3,370,000.00 106 GOK Butere District Hospital 6,000,000.00 107 GOK Busia District Hospital 5,047,000.00 108 GOK Coast PGH 10,586,865.00 109 GOK Hola D.H. - 110 GOK Ngao SDH 16,000,000.00 111 GOK Wesu D.H. 3,000,000.00 112 GOK Voi DH 7,573,930.00 113 GOK Taveta Hospital 2,396,114.00

/49 Table4.1: Ministry of Health's Ongoing Projects - 2005/06 Project KSh Source 114 GOK Kwale D.H. 10,500,000.00 115 GOK Kinango SDH 5,000,000.00 116 GOK Msambweni S.D.H 13,460,560.00 117 GOK Kilifi D.H. 2,000,000.00 118 GOK Malindi D.H. 2,000,000.00 119 GOK Port Reitz D.H. 2,000,000.00 120 GOK Lamu D.H. 2,000,000.00 121 GOK Garissa DH 6,467,952.00 122 GOK Wajir D.H 4,245,450.00 123 GOK Masalani D.H 6,000,000.00 124 GOK El Wak SDH 6,215,000.00 125 GOK Rhamu SDH 9,655,700.00 126 GOK Mandera D.H. 4,000,000.00 TOTAL (KSh) 1,036,180,801 Source: 2005/06 Estimates of Development Expenditure

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 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 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 2005/06 Vote head/type Description mount (KSh) Amount (KSh) Utilities (mainly 57,781,145 35,275,301 Recurrent water) Telephone 11,000,000 4,527,230 Other 25,449,434 Total recurrent 94,230,579 39,802,531 Development 3,447,390 118,479,103.30 Total (recurrent + 97,677,969 Development) 158,281,634.30 % of Total MOH 0.5 0.07 expenditure

5.1 Recommendations

 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.

/52  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

5 Analysis of Ministry outputs and corresponding performance indicators

5.1 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 The BOP did not extend the targets to 2008/09. 8 Current status(achievements)

/53 3. Proxy for Percentage of ANC 54 56 65 70 Maternal coverage (4 Visits) Mortality

4. Proxy for Inpatient malaria 19 18 15 14 Burden of morbidity as percentage Disease of total in-patient morbidity

5.2 Overview of Sector Performance Indicators and Targets

Overview of Sector Performance Indicators and Targets, NHSSP II/AOP 2, 2006/07

/54 Achievement Achievement Indicators National for Projected Performance Targets reporting national against Baseline 05/06 districts (61) achievement target Below 80% Achievement %Deliveries conducted by skilled health staff 42% 51% 15% 15% 30% District Aqua Laboratories in place 80 28 28 35% # School children correctly de- wormed at least once in 2005/06 25% 35% 7% 13% 36% # HIV+ve patients starting with ART 8,000 95,000 38,320 38,320 40% % Pregnant women sleeping under LLITN 0.44 44% 20% 20% 45% # LLITN distributed to children under 5 yrs 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% # Condoms distributed (million) 80,000,000 90,000,000 37,422,850 66,030,516 73% % Children < 1yr vaccinated against Measles 74% 84% 64% 64% 76% Above 80% Achievement % Children fully immunized at 1 year of age 58% 68% 56% 56% 83% Blood collected screened for HIV 0.98 1 1 1 100% Regional Food/Bacteriological Lab. Established 8 7 8 100% % Newborns that receive BCG 84% 90% 99% 99% 111% # Health Facilities providing Basic/Comprehensive Emergency Obstetric Care (BEOC / CEOC) 9% 15% 18% 18% 122% # Houses sprayed with IRS 2,500 200,000 367,000 367,000 184% % Pregnant women received IPT 2x 4% 20% 43% 43% 214% LLITN distributed to pregnant women 55000 200000 251,872 456,771 228% % House Holds implementing hygiene practices 25% 58% 58% 234% # HF providing treatment as per IMCI guidelines 2% 10% 35% 35% 353% # HF offering Youth Friendly Health Facilities 5 5 47 47 940% # CORPs selected and trained 100 10024 10024 10024%

5.3 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 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 5.4.2 Drug Procurement The process of drug procurement need to be made transparent in order to ensure the public gets value for money. Enhancing transparent and reducing opportunities for rent seeking are some of the conditions precedent to Kenya accessing the Millennium Challenge Account funds. The ministry will put mechanisms top ensure that information on drug tenders are published and hosted in the website.

5.4.3 Access to ARVs User fees charged to HIV/AIDS patients are hindering access and constraining the attainment of the 3 by 5 objective. In order to remove this barrier, user fees have been reduced to Ksh 100 per month. It is expected that this policy initiative will enable us provide ARVs to more than 95,000 people by 2006.The ministry is putting in place measures to ensure access for children suffering from HIV/AIDS.Currently 10000 children are on ARVs

5.4.4 Restructuring of the Ministry The current structure of the Ministry is not appropriate for efficient delivery of services. In the restructuring process, the focus will be to have a leaner centre, which will provide policy and regulation, while building capacity at the district level to deliver healthy care services. To improve access to health care the Ministry will develop a policy based on facility workload, distance to the facility, human resource deployment and catchment area. The new organogram will be part of the Ministry five-year strategic plan.

5.4.5 Restructuring of Parastatals

The ministry will ensure that the performance contracts are adhered to. The Ministry is also exploring ways of converting KNH to a fully-fledged teaching hospital

6 Public Expenditure Management (PEM)

Public expenditure management (PEM) is a central instrument of economic and development policy. Key goals of PEM are fiscal discipline, strategic resource

/57 allocation and good operational management. Effective PEM is also a key component in good governance, which rests upon the 'four pillars' of accountability, transparency, predictability and participation.

Accountability holds officials responsible for their actions. Transparency involves ensuring access to relevant information. Predictability results from an environment in which laws and regulations are clear, known in advance, and uniformly and effectively enforced. Participation requires the existence of channels through which reliable information is provided, enabling all stakeholders at all levels to be involved in the consultation and decision-making process.

On the whole the PEM framework pursued by the MoH is based on the following objectives:  Fiscal discipline, or living within the available resources;  Allocative efficiency, or spending money on the right things; and  Operational efficiency, or obtaining the best value for money.

It is proposed that monitoring of the budget will be done by conducting a Public Expenditure Tracking Surveys (PETS), which will provide quantitative and qualitative evidence on budget execution and accountability and transparency of transactions.

The Public Expenditure Review and PETS can assess the effectiveness of public expenditure and makes recommendations as to how public funds can be better spent.

Another way of monitoring the over all use of resources in the health sector is the use of a National Health Account (NHA). A NHA is a tool for gathering and analysing health expenditure data for a given period. It asks the fundamental questions: who pays, how much and for what? NHAs link ultimate sources of funds to financial agents and claims on pending by different users. “Users” can be classified as providers (e.g. government health centres, or private practitioners), functions (curative, preventive), service delivery level, (tertiary, secondary), inputs (transport, salaries), different socio-economic groups (rural/urban, wealth, gender, age), geographical locations and disease profiles.

6.1 Budget Preparation Process

The budget preparation process should aim at (i) ensuring that the budget is appropriate to macro-economic objectives and that expenditures are controlled; (ii) allocating resources to programs that fit the policy objectives in the health sector; and (iii) securing conditions for operational efficiency. During budget preparation, trade-offs and prioritisation among programs are made to ensure that the budget fits government priorities.

/58 Treasury in consultation with stakeholders prepares the Budget Outlook Paper (BOP) ready for release in December. This Paper is necessary because it provide the ceiling for each ministry.

The BOP provides three-year medium-term spending projections by sector. These are necessary to demonstrate to the public the desired direction of change. By illuminating the expenditure implications of current policy decisions on future years budgets, multi-year spending projections allow sectors to evaluate cost effectiveness and to determine whether they are attempting to undertake more than they can afford.

NHSSP II reinforces the decentralization process, with lower levels setting their own priorities according to their own needs and subsequently developing appropriate interventions. This is in line with both the Kenya Health Policy Framework for 1994–2010 and the government’s decentralization policy, articulated in the District Focus for Rural Development Strategy.

In this regard, the development of AOP 2 adopted a bottom-up planning process, beginning with revision and preparation of guidelines and planning tools. The district health plan format was re-designed to respond to the KEPH concept. This was followed by dissemination of NHSSP II to DHMTs, PHMTs, and the central divisions and programmes. An extensive training programme provided the necessary support to build the capacity of all participants to carry out their tasks. It is envisaged that this approach will greatly strengthen the various planning levels and in addition promote ownership of developed plans.

6.2 Results-Oriented Public Expenditure Management

Public Expenditure Management (PEM), as a major component of the reform Programme, continue to make use of the following mechanisms:

 Use of the budget as instrument for ensuring desired results;  Strengthening of existing structures to advocate and implement reforms; and  The establishment of clear targets and assessment mechanisms to ensure transparency.

Results-oriented (or ‘performance’ or ‘output’) budgeting is the planning of public expenditures for the purpose of achieving explicit and defined results. These results may be policy objectives (‘outcomes’), or the ‘outputs’ of routine public service activities intended to contribute to policy goals, or ‘intermediate outcomes’ which represent major stepping stones in service delivery towards these goals.

/59 Performance budgeting and management help to: a. Clarify policy priorities, b. Focus expenditures more tightly on priorities, c. Inform and motivate programme managers and service Providers, d. Identify the causes of good and bad performance and thereby reduce waste and increase impact, and e. Facilitate cross-institutional working. They are easiest to apply and most fruitfully applied to the production of services for the public.

6.2.1 Results-Based Management

The GOK has adopted the results-based management (RBM) approach as a leading principle in its efforts to enhance the productivity and improve the performance of the various ministries. The MOH is one of the ministries where RBM was introduced in an early stage, when the previous Permanent Secretary (PS) signed a performance contract spelling out the targets and outputs the MOH had to achieve within one year (2005/06).

7 Human Resources Development and Capacity Building Human resource development is increasingly being recognised as key to improved health service delivery and health sector transformation. Policies do acknowledge that health is a human system, and that reforms have to address themselves centrally to the personnel staffing the service, improving planning, capacity and management. Yet, there is concern about the equitable distribution of the key health personnel.

By far, the most significant component of any health system is its health personnel. Without a foundation of skilled human resources, health care systems cannot function adequately or effectively, particularly in the public sector and at the primary level of care.

No doubt, health systems can improved in their performance when there are improvements in the deployment and orientation of health personnel towards major health problems and improvements in the effective use of staff time. Research from other countries shows a correlation between quality of care, health care outcomes and the availability of health personnel9, 10.

9 Mercer H, Dal Poz M, et al. Human Resources for Health: Developing Policy Options for Change. Geneva: World Health Organization; 2002. URL: http://www.who.int/entity/hrh/documents/en/ Developing_policy_options.pdf

10 ICN. Position Statement: Nurse Retention, Transfer and Migration. Geneva: International Council of Nurses; 1999.

/60 7.1 Service Delivery Inputs

The NHSSP II recognizes that human resources, infrastructure and commodities are the primary tangible inputs into the delivery of health care services.

Availability of skilled human resources in adequate numbers is critical for the realization of the sector mission to deliver quality and accessible health services, more so if KEPH is to be implemented as planned.

There is an apparent gap in human resources when compared with norms and standards and the targets to be achieved in the next four years. A recent survey of the MOH personnel showed a necessary staff establishment of 44,813, of which 35,627 posts are filled (80%).

The same survey also brought out important disparities in the distribution of staff, with rural and isolated areas having very few staff. Moreover, the environment in which health personnel work is considered poor. In particular, the physical infrastructure is inappropriate and much of the equipment is lacking or non-functional. Other constraints include:

 MOH cannot control the number of staff it has, as human resource management functions are decided at the level of the Directorate of Personnel Management (DPM).

 There is currently an embargo on the recruitment of new staff, although special funds (like the Global Fund to Combat AIDS, Tuberculosis and Malaria – GFATM – and the President’s Emergency Plan for AIDS Relief – PEPFAR) allow for additional staff on a temporary basis.

 There is under utilization of staff in some areas (rural and isolated), excess workload in others (district and provincial hospitals), and critical shortages in level 2 facilities (50% of the dispensaries had only one staff member managing the health facility).

 Attitude of staff is not always positive (due to long hours, low salaries, lack of equipment, low morale). This has an effect on staff–patient relations. 7.2 Human resources situation

Kenya faces a variety of health personnel problems. These include an overall inadequate number of personnel in key areas of the health sector; an inequitable distribution of those health personnel who are available; and an attrition of trained personnel from the health sector and from the country. Yet the challenge is even more daunting when seen in the light of the additional health facilities that are being put up under CDF and the MoH expected to take over and staff and equip them. But all in all, MoH is committed to fundamental reforms to improve

/61 efficient of health services in the health system, including its human resources.

The mal-distribution of health care personnel occurs mainly between:  Public and private sectors;  Urban and rural areas;

In a number of instances, key health personnel shortage is more as a result of mal-distribution of human resources rather than actual or absolute numerical shortages. The human resource disparities occur in terms of:  Geographical spread; and  Professional category

Inequitable distribution of human resources is an inter-provincial as well as an intra-provincial problem. Table 7..2 shows the distribution of the MoH health personnel. Of all health professionals working in Kenya public health sector, the North Eastern Province has:  1.3% of all doctors;  2.0% of all nurses

Table 7.2: Total Number of Personnel by Profession and Province in 2004-2005 Nairobi Rift Valley

Moi North Referral Rest of Rest of Central Coast Eastern Nyanza Western Total KNH Total Eastern & Rift Total Nairobi Teaching Valley Hosp Staff type 2 Doctors 218 328 546 156 115 178 0 104 55 231 286 81 1,486 Clinical officers 61 125 186 278 212 336 78 285 69 651 720 221 2,316 Registered nurses 866 250 1,116 561 343 487 87 341 206 775 981 257 4,173 Enrolled 1,49 2,31 1,09 2,36 26 3,21 nurses 824 670 4 3 9 5 2 1,599 285 0 3,495 1,526 14,153 Pharmacists 10 104 114 25 12 21 1 12 3 28 31 9 225

Pharmaceutical technologists 45 31 76 22 26 47 18 25 23 72 95 21 330 Laboratory 2 technologist 115 132 247 216 102 201 6 179 35 315 350 132 1,453 Laboratory technicians 30 69 99 37 93 69 19 40 10 168 178 45 580 Radiographers 35 18 53 49 27 50 9 41 22 75 97 22 348 Health administrative officers 32 14 46 24 13 26 1 14 30 24 54 16 194 Public health officers/public health technicians 20 228 248 652 340 664 118 505 10 1,370 1,380 376 4,283 Nutritionists 56 50 106 64 29 42 9 24 31 119 150 26 450 Social workers 28 10 38 1 - 2 - 2 22 5 27 4 74

/62 2,47 3,79 1,35 1,28 o) All others 6 1,321 7 6 736 1,473 149 0 1,010 1,718 2,728 686 12,205 4,81 3,35 8,16 5,75 10,57 3,42 TOTAL 6 0 6 4 3,147 5,961 797 4,451 1,811 8,761 2 2 42,270

7.3 Human resource disparities

Table 9.1 shows that mal-distribution of professionals is worse in provinces with:

 Sparsely populated areas characterized by vast distances, especially North Eastern province,

 Deep-rural and remote districts with lack of general infrastructure

 Various types of health facilities, particularly dispensaries

Table 9.2: Selected health personnel, Rates per 100,000 population Staff type Nairobi Central Coast Eastern North Nyanza Rift Valley Western Total Eastern Doctors 546 156 115 178 20 104 286 81 1,486 Number per19.8 3.9 3.9 3.5 1.4 2.1 3.4 2.1 4.4 100,000 population

Clinical officers 186 278 212 336 78 285 720 221 2,316 Number per6.8 6.9 7.2 6.6 5.4 5.8 8.6 5.7 6.9 100,000 population

All Nurses2,610 2,874 1,442 2,852 349 1,940 4,476 1,783 18,326 (Registered & Enrolled) Number per94.8 71.2 49.3 55.7 24.3 39.5 53.5 45.9 54.8 100,000 population

Pharmacists 114 25 12 21 1 12 31 9 225 Number per4.1 0.6 0.4 0.4 0.1 0.2 0.4 0.2 0.7 100,000 population

Source : Human resource Mapping 2003

Table 9.1 reveals inequities in access to health professionals in the public sector. Nairobi, including KNH (19.8 per 100,000 population) and Central (3.9) and Coast (3.9) provinces are better staffed with doctors than the other provinces.

/63  In Western and Nyanza provinces, there is one public sector doctor for every 47,000 population. In the North Eastern Province the ratio is much worse with one doctor for every 72,000 people in the public sector.

 The North Eastern Province has one public sector nurse per 4,100 populations, compared to central province, where there is 1 nurse for 1,400 people, and for every 1050 population in Nairobi,  There is only one public sector clinical officer for every 18,400 people living in the North Eastern Province, for every 14,500 people in central, and for every 13,800 people in the coast province.

It should be notes that although Nairobi is comparatively well resourced with doctors, many of these doctors work at tertiary level (KNH).

A number of strategies have been implemented to increase the number of key health personnel in the public sector including employment of more key health personnel e.g. nurses; laboratory personnel under the PEPFAR /Clinton Foundation arrangement.

As seen from Table 9.3:  A total of 7,450 staff has been recruited during the period 2001- 2006

 There was no discrimination in the recruitment.

Table 9.3: Number of Staff employed by year and type Cadre 2001 2002 2003 2004 2005 2006 Total Clinical Officer 119 158 93 201 24 272 867 Enrolled Nurses 536 362 240 400 220 1,791 3,549 Nursing Officers 229 236 169 356 94 542 1,626 Medical Officers 116 158 261 162 248 309 1,254 Medical 0 0 0 0 8 146 154 Laboratory Technologists TOTAL 1,000 914 763 1,119 594 3,060 7,450

/64 7.4 Impact of HIV/AIDS on Human Resources

Any human resource plan for health in Kenya must take into account the increased load placed on existing staff due to HIV/AIDS, and the attrition of health care workers due to AIDS related mortality.

In a study on human resources mapping, obtaining information on short-term and long-term sickness proved very difficult during the survey with the MoH staff reluctant to talk about staff affected by HIV/AIDS, yet AIDS and AIDS-related illness is known to be affecting significant numbers of medical staff. All in all, information about all sickness issues – whether short- or long-term is essential to inform HR planning. A VCT centre has been established at the MOH Headquarters and is operational. The facility is open to both staff and the general public.

8 Implementation of Recommendations of the 2006 PER

The 2006 Ministry of Health PER is part of the continuing series of MPER, and builds on the previous year PER. While its production was hampered by numerous constraints, notably data and time, it made several key recommendations that have been acted upon during the year by the Ministry of Health. These are summarised in point form below as an Action Plan and the Activities and Broad Actions to implement them.

8.1 Action plans for implementation of 2006 MPER

 The level of Government funding on health has increased in line with the ERS. However, the allocations are only 8.4 percent of the central Government allocation a figure far below the Abuja declaration targets.

 The personnel costs take 53% of MOH recurrent expenditure. In 2004/05 spending on personnel represented 52 percent of the total recurrent funding. , suggesting that these costs may be stabilizing;

 Curative Health service accounted for about a half (50.6%) of the recurrent expenditure on health, although this share has been falling since 2000/01 and stood at less than a half in 2004/05.

 The share of Kenyatta National Hospital decreased from 16.2% in 2002/2003 to 15.3 percent in 2004/05 and further to 14.5% in 2005/06.

Substantial expenditure on Development were directed towards the rural health services increased from 26.8% in 2004/05 to 28.2% in 2005/06 and about 54

/65 percent to Preventive and Promotive while just under 10% went to the strengthening the Curative Health services.

Cost sharing accounted for about 12 percent of the ministry recurrent budget. The bulk of these collections are in hospitals. The health facilities are witnessing an increase on waivers and exemptions since patients are unable to pay. An arrangement need to be made to compensate health facilities for loss in revenue. There is need to critically examine utilization of these funds in light of the many audit queries being raised by Controller and Auditor General. In response to this, the Ministry has intensified monitoring and supervision systems on collection, custody, control, programming and expenditure of funds. Corrective measures have been taken on areas that funds have not been accounted for.

Release of money through AIEs to the districts has been a bottleneck to expenditures at the district level. In 2005/6 Treasury allowed funds to be disbursed on pre-financing arrangements. This has ensured that facilities receive an AIE accompanied with a cheque to facilitated programmes implementation and expenditures.

It is hoped that in future grants will be issued to health facilities once a legal framework is developed. Currently, the Ministry has developed a position Paper and Guidelines in the flow of funds to the rural health facilities.

8.2 Activities and Supporting Actions

Develop a Geographical information system to provide district profiles on resource available, actors, and health indicators for better planning and resource allocation;

Develop a manpower projection model and a decentralisation policy; and

 Review resource allocation criteria.  Strengthen the DHMBs to oversee health care services at the district level; The BHMBs have been reconstituted and will be trained along with the management committees early in 2006.

8.3 Timeframes and targets

/66 9 Challenges and Constraints 9.1 Integrating NHSSP II and AOPs into the Annual Budget

The introduction of the NHSSP II, AOPs, BFR and Performance Contracts in 2005 has changed the landscape for the Ministry of Health budgeting. The challenge for the Ministry of Health is to ensure that the budget will reflect these developments.

The development of the KEPH provides a set of programmes to deliver the long- term goals of the Ministry of Health through the setting of short to medium term objectives. These are centred on the life cycle interventions:

. Pregnancy, delivery and the newborn child (up to two weeks of age) . Early childhood (3 weeks to 5 years) . Late childhood (6 to 12 years) . Adolescence (13 to 24 years) . Adulthood (25 to 59 years) . Elderly (60 years and over)and the five clusters of interventions . Safe motherhood and reproductive health . Child health promotion . Malaria control . HIV/AIDS/STI and TB control . Sanitation and food safety

While these interventions will be delivered mainly through the three lower levels of care: community, dispensary and health centre11, the KEPH targets also refer to the delivery through district and other higher level hospitals.

The challenge is to integrate the five clusters of interventions to the budgets of the delivery institutions and link them to the output indicators for the six levels of the life cycle. This will then tie in the inputs in the budget to specific programmes (cluster of interventions) through activities carried out in the various institutions to achieve the output targets of the six elements of the life cycle.

This will then link the annual budget to the objective of Results Based Management as expressed in the AOP and the various Performance Contracts. 9.2 Reviewing Targets

There is plethora of targets established for the Health sector. Chapter 9 reports on those set in the MTEF and ERS. Annexes I and II present those for KEPH and Performance Contracts. In addition there are targets expressed in the MDGs, although these are essentially subsumed in the MTEF and ERS targets.

11 As reported in Chapter 1

/67 Table 9.2 of AOP II Leadership outputs has the following output as part of the work programme, which has yet to be achieved.

Time Frame Outputs for 2005/06 2006/07 I II III IV

6.1. Leadership outputs

Indicators, targets and priorities are harmonised with NHSSP 75 II, ERS and MDG. X

The Performance Contracts are a mixture of process and procedural targets as well as operational ones. The operational ones are similar in style to the KEPH targets in that the measure output related to some heath indicator. However they are not necessarily the same targets.

It will be important that operational targets set in KEPH and in the Performance Contracts are the same given the challenge relating to the budget in the previous section. Therefore, the review and harmonisation of targets established in AOP II takes on a greater urgency and should be completed.

These are two challenges set out in this section. The constraints in achieving them will centre on the allocation of sufficient skilled personnel to the task and enough time for them to complete the task. This would suggest that a task force be established, but properly resourced. The challenges are complex and should not be hurried. They should be carried out in 2007 as inputs to the 2008 PER and the 2008/09 Budget.

10 Conclusions and Key Recommendations

By the 1970s, Kenya had built a health sector that performed relatively well compared to neighbouring countries, and some of its indicators were among the best in sub-Saharan Africa. However, these substantial gains made during the 1970s and the 1980s have been eroded to reflect a downward trend in health at the start of the new millennium. However there are important regional differentials; North Eastern, Coast, Nyanza and Western Provinces having the worst health indicators. Unless drastic actions are taken Kenya is unlikely to achieve the MDGs.

Although the level of Government funding on health has increased in line with the ERS, these allocations are only 8.73 percent of the central Government expenditures a figure far below the Abuja declaration targets.

/68 The personnel costs take 53% of MOH recurrent expenditure. In 2004/05 spending on personnel represented 52 percent of the total recurrent funding. , suggesting that these costs may be stabilizing; .

Curative Health service accounted for about a half (50.6%) of the recurrent expenditure on health, although this share has been falling since 2000/01 and stood at less than a half in 2004/05.

The share of Kenyatta National Hospital decreased from 16.2% in 2002/2003 to 15.3 percent in 2004/05 and further to 14.5% in 2005/06.

Substantial expenditure on Development were directed towards the rural health services increased from 26.8% in 2004/05 to 28.2% in 2005/06 and about 36 percent to Preventive and Promotive while 22% went to the strengthening the Curative Health services.

A comparison of the printed estimates and actual expenditures reveals that, the disbursement rates of development expenditure have been low. However, for the recurrent budget, the divergence between the printed or approved estimated and the actual expenditures is small – within a range of ±10% - with large over- spending in some sub votes have been cancelled out by large under-spends in other sub votes. With respect to development expenditures, the pattern is generally one of large under-spending.

Cost sharing accounted for about 12 percent of the ministry recurrent budget. The bulk of these collections are in hospitals. The health facilities are witnessing an increase on waivers and exemptions since patients are unable to pay. An arrangement need to be made to compensate health facilities for loss in revenue. There is need to critically examine utilization of these funds in light of the many audit queries being raised by Controller and Auditor General. In response to this, the Ministry has intensified monitoring and supervision systems on collection, custody, control, programming and expenditure of funds. Corrective measures have been taken on areas that funds have not been accounted for.

The findings of the 10/20 Policy study suggest that the overall impact has been mixed. Utilization of services in the sample facilities generally increased rapidly following the introduction of the policy. However, this growth was not sustained due primarily to non availability of drugs. In the last quarter of 2004 many facilities generally experienced declining utilization although the picture varies by district and according to the type of service and utilization 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.

/69 There is a consistent theme running through the I-PRSP and the PRSP which is to focus expenditures on rural health services and preventative and promotive health services and reduce the share of the total that curative health services consume. While this focus in not so specific in the ERSWEC, affordability and accessibility of health services for the poor is emphasised. Both policies are wholly consistent. However, the core poverty programmes in health sector are not as focused and are much wider in coverage and need to be reviewed.

The Ministry of Health has a total of ---- 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. At the same time, there are a total of about --- stalled projects whose cost of completion is estimated at Kshs. ---- billion. Most of these projects are being completed through Ministry of Public Works using the KSh 3 billion allocated for stalled projects in 2005/6.

Revised indicators and targets have been developed for the purpose of measuring the budget performance and the Government is commitment to the health sector in the Economic Recovery Strategy (ERS). These indicators form part of the current budget outlook paper and will be used to access provided by some Development Partners through budgetary support. The underlying policy principle to attain these targets is the one underlying all policy statements on health: shifting the focus from curative care to preventative care.

Release of money through AIEs to the districts has been a bottleneck to expenditures at the district level. In 2005/6 Treasury allowed funds to be disbursed on pre-financing arrangements. This has ensured that facilities receive an AIE accompanied with a cheque to facilitated programmes implementation and expenditures. It is hoped that in future grants will be issued to health facilities once a legal framework is developed. Currently, the Ministry has developed a position Paper and Guidelines in the flow of funds to the rural health facilities.

On human resources, considerable variation exists. North Eastern Province has 1 doctor per 100,000 populations compared to 4 each in Central and Coast Provinces are significantly higher. Central province has more than double (73) the number of nurses per 100,000 populations compared to North Eastern Province (28). A rational deployment policy is necessary to minimise these disparities in addition to decentralising the personnel functions to the districts. The human assessment for attainment of MDGs work currently being undertaken should form the basis for development of a long term manpower policy.

These achievements set out the basis on the way forward:

 Consolidate and strengthen these achievements;

/70  Integrate the Annual Operating Plans and the Annual Budget (recurrent and development);  Streamline outputs targets

11 Annexes

Annex 1: Inventory of Stalled Building Construction Projects – D11-Ministry Of Health % Year PROJECT NAME LOCATION COST COMPL. Complete Started Minor Theatre Children Wd Magutuni H/C 10 1998 Meru South 3,300,000 Kapsabet Hosp. Renov. 14 1993 Nandi 6,222,000 Kapsabet Hosp. 14 1988 Nandi 26,266,000 Embu PGH HOSP. 15 1984 Embu 250,000,000 Kipeto Disp. 15 1998 Kajiado 1,922,000 Lokitung Hosp. 20 1989 Turkana 63,000,000 Bunyala Hosp.Female Ward 30 1997 Bungoma 2,840,000 Tiva Disp. 38 1996 Kitui 2,000,000 Habasweni Maternity Ward 40 1996 Wajir 1,610,000 Kisii Dist. Hosp. Renov. 41 1991 Kisii 143,364,000 Pala H/C-Completion 45 1992 Homa Bay 1,282,360 Bondo Dist. Hosp Phase 1 45 1990 Siaya 30,000,000 Kaptarakwa H/C 45 1997 Keiyo 600,000 Simotwo H/C 48 1998 Keiyo 8,595,000 Kariko Disp. 50 1997 Nyeri 3,000,000 Nyagande H/C 50 1991 Kisumu 1,739,000 Migori Dist. Hosp.Type E Flat 50 1987 Migori 947,000 Budeta Disp.1No cat F House 50 1992 Busia 730,000 Mariakani HC Service Block 52 1990 KILIFI 2,500,000 Muuti-O-Kiama H/C 60 1998 Meru North 14,465,783 Longisa Dist. Hosp. Phase II 60 1990 Bomet 142,960,000 Msekewa H/C 60 1997 Keiyo 1,224,000 Busembe Disp. 60 1992 Busia 800,000 Agenga Disp 60 1998 Busia 500,000 Iguhu H/C 60 1986 Kakamega 7,547,595 Narok Dist. Hosp. 63 1994 Narok 3,612,000 Bondo Hosp. Fencing Works 65 1997 Bondo 747,000 Nanyuki Dist. Hosp. Renov. 66 1992 Laikipia 24,000,000 Kapcherop H/C 67 1988 Marakwet 3,985,000 Runyenjes H/C Completion of OPD 70 1986 Embu 5,490,000 Pumwani Nyayo Wards 70 1987 Nairobi 66,565,000 OlenguruoneH/C 70 1987 Nakuru 40,690,000 Kibish Disp. 70 1990 Turkana 7,975,434 Kiganjo H/C 73 1997 Nyeri 3,000,000 Staff Houses Dirb Goma Disp. 75 1996 Marsabit 956,000

/71 Annex 1: Inventory of Stalled Building Construction Projects – D11-Ministry Of Health % Year PROJECT NAME LOCATION COST COMPL. Complete Started Nuu H/C Exts 75 1981 Mwingi 8,507,000 Kabarnet MTC 75 1991 Baringo 150,000,000 Sugutar Marmar H/C 75 1990 Samburu 1,522,000 Vihiga Dist. Hosp 75 1989 Vihiga 96,653,600 Upgrading-Gichira H/C 80 1984 Nyeri 19,600,000 Nyamaraga Disp. 80 1995 Migori 262,000 Kagwa Disp.Fencing Work 80 1997 Siaya 247,000 Kapkatet Nyayo Hosp. 80 Buret 210,000,000 Bugina H/C 80 1996 Vihiga 10,583,780 Kathiani Hosp. Renovation 85 1989 Machakos 1,275,000 Yala Sub-Dist. Hosp. 85 1990 Siaya 5,000,000 Chulaimbo RHTC Staff Houses 86 1997 Kisumu 4,807,000 Isinya H/C Phase II 88 1997 Kajiado 2,622,000 Milo Disp Type F House 88 1996 Bungoma 500,000 Mutito H/C Fencing Work 89 1996 Kitui 500,000 Renovation work Githiga H/C 90 1981 Kiambu 3,870,000 Kunene Disp. Rehab.&Ext. 90 1996 Meru N 400,000 IPD &Service Block-Nyagoro 90 H/Bay CNV Female&Amenities Lodwar 90 1997 Turkana 540,000 Lodwar Comm. Nurses Training School 90 1988 Turkana 119,000,000 Busia VSCU 90 1991 Busia 10,000,000 Siaya Dist. Hosp.VSCU 94 1991 Siaya 500,000 Uyawi Disp. 94 1990 Siaya 1,804,000 Staff Houses at Kathiani Hosp. 95 1995 Machakos 206,428 Kotulo Disp.&Staff Houses 95 1997 Mandera 766,000 Homa Bay Hosp.Maint. Workshop 95 1991 H/Bay 726,000 Siaya Dist. Hosp.Renov. 96 1996 Siaya 120,000 Katito Disp. 97 1992 Kisumu 400,000 Kangundo Nyayo Wards 98 1993 Machakos 2,881,600 Mbeu RHDC 98 1983 Meru C 3,000,000 Ijara Disp. Completion of Ward 99 1996 Ijara 2,247,000 Kihara H/C 1996 KIAMBU 58,305,000 Muranga D. Hosp. 1997 Muranga 5,746,000 Rehab.&Ext.to Muriranjas Hosp. 1991 Muranga 20,341,200 Kanyanyaini New Disp. 1984 Muranga 2,643,880 Karatina Dist.Hosp.Renov. 1989 Nyeri 5,876,940 Karatina Hosp. Alt to Nyayo Wards 1997 Nyeri 2,000,000 Gichichi H/C High Level Water Tank 1985 Nyeri 1,200,000 Karatu H/C 1986 Thika 55,000,000 Mryachakwe Disp.Bock-Ganze 1997 Kilifi 5,452,540 Completion of Cat.F at Mwanda 1992 Kwale 582,000 Ext. Kitui Dist. Hosp. Kitui 930,000 Marsabit Hosp. Office Block 1996 Marsabit 400,000 Mtito Andei H/C 1988 Makueni 14,741,000 Timau Disp 1987 Meru Central 13,047,000 Mathare Nyayo Hosp. 1989 Nairobi 401,002,000 Medical Training Coll. Staff Houses 1987 H/Bay 40,000

/72 Annex 1: Inventory of Stalled Building Construction Projects – D11-Ministry Of Health % Year PROJECT NAME LOCATION COST COMPL. Complete Started Drugs Store for MOH 1988 Trans Mara 474,000 Cherangany Disp. Ext. 1997 Trans Nzoia 710,000 Webuye Hosp. Repair& Renov. 1996 Bungoma 1,550,000 Bungoma Dist. Hosp. Amenity Wards 1993 Bungoma 2,780,000

TOTAL 2,122,497,140

Annex __: The list of core poverty Projects/Programmes

1 Health Dev. Project - IDA 11 DARE Sexually Transmitted Infections 2 Revolving Drug Fund 12 District Hospitals 3 Supply of Medical 13 equipment Mental Health Services 4 Decentralisation of District 14 Health Spinal Injury Hospitals 5 Health Sector Reform 15 Dental Health Services 6 Environmental Health 16 Communicable and Vector borne Services Diseases 7 Rural Health Centres & 17 Dispensaries Nutrition Programme 8 Rehabilitation of District 18 Family Planning Maternal & Child Hospitals Health Care 9 Rehabilitation of Mortuaries 19 Rural Health Centres & Dispensaries 10 National AIDS Control 2 Rural Health Training and Programme 0 Demonstration Centres

12 References

a) Ministry of Health. 2006. “Public Expenditure Review, 2006.” Unpublished. Nairobi.

b) Ministry Of Health: RHF Unit Cost/Cost Sharing Review Study & The Impact Of The 10:20 Policy, 2005

c) Kenyatta National Hospital, Strategic Plan 2005-2010

d) Kenya Medical Research Institute, Strategic Master Plan 2005-1015. (2005);

e) Ministry Of Health, Report On Human Resource Mapping And Verification Exercise

/73 f) Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH and ORC Macro

星期二, 一月 09, 2018