An Assessment of Healthcare Delivery in Kenya under the Devolved System Phares Mugo, Eldah Onsomu, Boaz Munga, Nancy Nafula, Juliana Mbithi and Esther Owino Special Paper No. 19/2018 KENYA INSTITUTE FOR PUBLIC POLICY RESEARCH AND ANALYSIS (KIPPRA) An Assessment of Healthcare Delivery in Kenya under the Devolved System Phares Mugo, Eldah Onsomu, Boaz Munga, Nancy Nafula, Juliana Mbithi and Esther Owino Social Sector Department Kenya Institute for Public Policy Research and Analysis Special Paper No. 19 2018 An assessment of healthcare delivery in Kenya under the devolved system KIPPRA in Brief The Kenya Institute for Public Policy Research and Analysis (KIPPRA) is an autonomous institute whose primary mission is to conduct public policy research leading to policy advice. KIPPRA’s mission is to produce consistently high-quality analysis of key issues of public policy and to contribute to the achievement of national long-term development objectives by positively influencing the decision-making process. These goals are met through effective dissemination of recommendations resulting from analysis and by training policy analysts in the public sector. KIPPRA therefore produces a body of well-researched and documented information on public policy, and in the process assists in formulating long-term strategic perspectives. KIPPRA serves as a centralized source from which the Government and the private sector may obtain information and advice on public policy issues. Published 2018 © Kenya Institute for Public Policy Research and Analysis Bishops Garden Towers, Bishops Road PO Box 56445-00200 Nairobi, Kenya tel: +254 20 2719933/4; fax: +254 20 2719951 email: [email protected] website: http://www.kippra.org ISBN 9966 058 80 5 The KIPPRA Special Reports Series deals with specific issues that are of policy concern. The reports provide in-depth survey results and/or analysis of policy issues. They are meant to help policy analysts in their research work and assist policy makers in evaluating various policy options. Deliberate effort is made to simplify the presentation in the reports so that issues discussed can be easily grasped by a wide audience. KIPPRA appreciates any comments and suggestions arising from this report. ii Acknowledgements The development and subsequent publication of the Heath Assessment Study was made possible through financial support to KIPPRA by the Government of Kenya, the Africa Capacity Building Foundation (ACBF) and Think Tank Initiative (TTI) of IDRC; and inputs from all the 47 counties in Kenya, National Government and other health sector stakeholders. We therefore wish to thank all the County Government teams consulted, ably led by their respective Governors, County Executive Members and County Directors in charge of health. Second, we acknowledge the KIPPRA Board of Directors and the Executive Director for providing technical guidance and oversight in the development of this report, right from the inception to publication of the report. Specifically, the study was guided by KIPPRA’s Executive Director, Dr Rose Ngugi. The KIPPRA technical team comprised Dr Eldah Onsomu, Mr Phares Mugo, Mr Boaz Munga, Dr Nancy Nafula, Ms Juliana Mbithi and Ms Esther Owino. The Institute would also like to thank the field coordinators, research assistants and Ms Rose Ngara-Muraya, who gave some contributions during the inception stage. The Institute also acknowledges invaluable comments from Dr Hellen Kiarie (Ministry of Health) and Dr Othieno Nyanjom who were discussants of the study during the national level validation workshop. Finally, the Institute is grateful to the various stakeholders who participated in County and National validation and dissemination workshops, and the Kenya National Bureau of Statistics for designing the study sampling framework. While every effort has been made to verify the contents of this report at the time of writing, the authors alone retain responsibility for the accuracy of the views expressed and the evidence presented. iii An assessment of healthcare delivery in Kenya under the devolved system Executive Summary Access to and provision of quality health care is a basic right guaranteed by the 2010 Constitution of Kenya. In the Kenya Vision 2030, the government targets to have the entire population having access to quality and effective health services. Further, the government emphasizes on Universal Health Care (UHC) coverage in the “Big Four” Agenda. Devolution of the health services has granted county governments the role of coordinating and managing the delivery of county healthcare services including promotion of primary health care, public health and sanitation, ambulance services, disease surveillance and response among others. The national government coordinates and manages the national referral hospitals and laboratories, planning and budgeting for national health services, and Health Information Management Systems (HIMS). The roles of the two government systems are coordinated by the County Health Bill (2016) that provides a regulatory framework for health care services and service providers, health products and health technologies. Four years into devolution of public health care delivery, therefore provided a good opportunity to assess the status of health care services in the country. In this regard, KIPPRA undertook the study titled “An Assessment of Healthcare Delivery under Devolution” to evaluate the delivery and uptake of health care services in the country with the accession to devolved system of government in 2013. The study mainly focused on: the extent of citizen participation in planning and budgeting for the sector; exploring citizens’ uptake of and perceptions on primary health care services in the context of a devolved system; level of citizens’ satisfaction with the health services; availability of health inputs (human, capital, commodities) in primary health care facilities. Public participation in health policy process Public participation in policy process is provided for in the constitution. In the health sector it is expected that public will be involved in the planning and budgeting of health care to in enhancing health systems and outcomes. However, there was limited awareness among citizens on their role in the health policy making, planning and budgeting process across all counties. This was attributable to limited access to information by citizens on how they can engage with county duty bearers as well as lack of structures for health public participation to guide the process. To ensure effective public participation, a clear public participation framework for health should be formulated and implemented. There is also need iv for a clear channel of communication and relevant structures to allow public engagement, enhanced civic education and capacity-building of the county officials to facilitate social accountability and productive policy engagement, respectively. Improved health sector performance There was significant improvement in the health sector performance, although the country lags various international benchmarks such as WHO targets and the 2001 Abuja Declaration. Child survival improved over the last five decades, with reduction of under-five, infant, neonatal and maternal mortality. Nutrition status of children also improved there were significant disparities across the counties where especially the ASAL areas recorded relatively high levels of stunting, wasting and underweight. Communicable disease burden declined significantly due to efforts by the government to combat preventable diseases such as Malaria and Tuberculosis (TB). HIV prevalence declined marginally with the country achieving its ART coverage target of 1.03 million people in 2016. However, adolescents continue to bear the biggest brunt of new HIV cases. More importantly, significant efforts are required to address the increasing burden of non-communicable diseases including cancer, hypertension and diabetes. Investing in human resources for health Human resources for health (HRH) are requisite for delivery of better health services and outcomes. For efficient service delivery, HRH should be quality, adequate and equitably distributed. Despite the impressive growth in the number of health workers, most counties are yet to meet the national health human resource norm of 3 health workers per 10,000 population. Furthermore, various challenges persist including inadequate and inequitably distributed of workforce as well as a non-conducive environment that attracts and retains health workers. HRH across counties also lack effective training, capacity building and general workforce development, across all categories. Given that HRH challenges are interrelated and multi-sectoral, more holistic interventions encompassing policy, education/training, leadership/stewardship, finance, partnership and better human resources management are recommended. Improving health infrastructure Adequate health system infrastructure enhances access to health care and contributes to high quality of outcomes. With the devolved function, significant investment has gone into increasing the number of health facilities especially v An assessment of healthcare delivery in Kenya under the devolved system those at lower levels. As a result, the average density of health facilities in the country has increased, but it falls below the WHO minimum threshold, and there are disparities across the counties. In addition, there was a weak balance between level of health infrastructure development and provision of