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Improving Resource Allocation in Kenya's Public IMPROVING RESOURCE ALLOCATION IN KENYA’S PUBLIC HEALTH SECTOR MARCH 2010 This publication was produced for review by the U.S. Agency for International Development (USAID). It was prepared by Brian Briscombe, Suneeta Sharma, and Margaret Saunders of the Health Policy Initiative, Task Order 1. Suggested citation: Briscombe, Brian, Suneeta Sharma, and Margaret Saunders. 2010. Improving Resource Allocation in Kenya’s Public Health Sector. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. The USAID | Health Policy Initiative, Task Order 1, is funded by the U.S. Agency for International Development under Contract No. GPO-I-01-05-00040-00, beginning September 30, 2005. Task Order 1 is implemented by Futures Group International, in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), and Futures Institute. IMPROVING RESOURCE ALLOCATION IN KENYA’S PUBLIC HEALTH SECTOR MARCH 2010 The views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government. TABLE OF CONTENTS Acknowledgments ...................................................................................................................................... iv Executive Summary .................................................................................................................................... v Abbreviations ............................................................................................................................................ vii I. Introduction .......................................................................................................................................... 1 Purpose ................................................................................................................................................... 1 Methodology .......................................................................................................................................... 1 Rationale for Intervention: Distribution of Poverty in Kenya ................................................................ 2 II. Findings of the Literature Review on Health Resource Allocation ................................................. 6 Overview on Resource Allocation .......................................................................................................... 7 III. Findings on Resource Allocation in Kenya ........................................................................................ 9 Background ............................................................................................................................................ 9 Resource Allocation among Government Ministries and Sectors ........................................................ 10 Kenya’s Public Health Budget in Perspective ...................................................................................... 12 FP/RH’s Share of the Public Health Budget ........................................................................................ 13 Resource Allocation within the Public Health Sector .......................................................................... 15 Kenya’s Resource Allocation Criteria (RAC) Formula ....................................................................... 15 District-level Budgeting ....................................................................................................................... 16 District-level Resource Allocation ....................................................................................................... 17 Reconciling District-level Requests with Health Resource Allocations .............................................. 19 IV. Findings on Women’s Participation in Resource Allocation .......................................................... 21 Obstacles to Women’s Participation in the Resource Allocation Process ............................................ 21 Findings of the Legal Review ............................................................................................................... 22 Findings on Kenyan Law in Relation to FP/RH ................................................................................... 23 The Effects of Kenyan Laws on Women’s Participation in Resource Allocation for FP/MH ............. 24 The Financial Management Act of 2004........................................................................................ 24 Legal Notice 162 of the Public Health Act, 1992 .......................................................................... 25 V. Conclusions and Recommendations ................................................................................................. 26 Annex A: The Eight Provinces of Kenya (numbers) and Health Policy Initiative Study Districts (dots) ......................................................................................................................... 29 Annex B: Poverty Map of Kenyan Districts ........................................................................................... 30 Annex C. Findings of the Literature Review: Summary Table ............................................................ 31 Annex D. Findings of the Literature Review: Case Studies .................................................................. 36 References .................................................................................................................................................. 43 iii ACKNOWLEDGMENTS The authors thank the following experts for their ideas and insights, which are reflected in this report. • Prof. Germano Mwabu, School of Economics, University of Nairobi • Prof. Patricia Kameri-Mbote, Consultant on Kenyan Legal Affairs, Strathmore University • Dr. Eric Othieno Nyanjom, Kenya Institute for Public Policy Research and Analysis • Dr. Dayl Donaldson, Economist, Health Policy Initiative, Task Order 1, Futures Group • Mr. Sam Munga, Head/Division of Health Care Financing, Ministry of Medical Services, Government of Kenya • Dr. Josephine Kibaru, Head/Division of Family Health Services, Ministry of Public Health and Sanitation, Government of Kenya • Dr. Janet Wasiche, Department of Reproductive Health Services, Ministry of Public Health and Sanitation, Government of Kenya • Dr. Per Tidemand, Managing Director, Dege Consult • Mahesh Karra, Economist, Health Policy Initiative, Task Order 1, Futures Group iv EXECUTIVE SUMMARY This report examines equitable financing and resource allocation at decentralized levels for family planning (FP) and reproductive health (RH) programs in Kenya. The USAID | Health Policy Initiative, Task Order 1 investigated the institutional, legal, and political environment affecting budgetary decisionmaking in the public health sector. The research team focused on how budgetary planning and resource allocation functions under decentralization and how decentralization affects equity in resource allocation for FP and RH. The Health Policy Initiative analyzed the legal and political criteria used to allocate health resources among Kenyan provinces by conducting (1) a preliminary literature review on health resource allocation in developing countries; and (2) Kenya-specific research—including a literature review; a formal survey targeting health sector professionals, FP clients, and other stakeholders; research and focus group discussions on women’s participation in the health resource allocation process; and a review of Kenyan laws related to FP/RH services. The rationale for this research—in the context of rising poverty and unequal distribution of health resources across regions and programs—was that a multifaceted analysis of the government’s health resource allocation decisionmaking processes should reveal ways to improve equity in access to healthcare. Study Findings Decentralization has been a stated policy objective for Kenya since 1994; however, the allocation of health sector financial resources remains highly centralized and opaque, relying primarily on previous years’ budget allocations rather than on health needs indicators. Equitable or fair resource allocation can only be accomplished by considering variation in needs across geographic and economic groups. The Health Policy Initiative’s research revealed that the allocation of health sector funds in Kenya has not accounted for differences in health achievement, access, and provision costs across the regions, provinces, and districts. As part of its analysis, the research team examined the extent of women’s participation in the health budget allocation processes. There is a logical correlation between women’s representation on budgetary committees and increased attention to programs that affect women’s health, such as FP/RH programs. Findings from surveys, focus groups, and interviews support this correlation between increased representation of women in health resource allocation decisionmaking and increased attention to FP resource allocation. Although obstacles exist to women’s participation, a 2004 legal decree mandates minimum female representation on select budget committees at all sub-regional levels. Recommendations Kenya could further improve equity in resource allocation across subnational governments and at the decentralized level. The government could also take steps to further promote women’s participation in decisionmaking, as a means of supporting women’s involvement in local planning and management of FP/RH
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