Kenya’s Health Sector Budget: How
Aligned is it to the Child National
Health Priorities?
International Society for Child Indicator’s (ISCI)
Conference, held in York, UK
27th – 29th July 2011
Albert Mwenda, Robert Peter Ndugwa, Isa Achoba and Godfrey K. Ndeng’e,
The opinions expressed are the personal thoughts of the contributors and do not necessarily reflect the
policies or views of the institutions or any other organization involved and named in this paper
Government of Kenya
1
Outline
• Introduction
• Data and Methods
• Results
• Discussions
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
2
INTRODUCTION
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
3
Kenya’s Profile
• Location:
– East Africa;
– Borders Somalia and Indian Ocean in the east; Ethiopia and South
Sudan in the North; Uganda in the West and Tanzania in the South.
• Population: 38.6 million (males – 49.8% and females – 50.2%).
• Approximately half of the population is poor.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
4
In 2009/10, most health indicators for children and
women were off the set sector targets
Health Indicator
Unit of Measure
Sector Target –
2009/10
Achievement -2009/10
Under 5 Mortality rate
Per 1,000 live
births
55
74
Maternal Mortality rate
Per 100,000
254
488
Skilled attendant at
Birth
Percent (%)
64
43
Immunization Coverage % of children
under 1 year fully
immunized
85
77
Access to HIV
healthcare services
60
56.2
% of patient on
ARVs
Source: Republic of Kenya (RoK), 2011. Second Annual Progress Report on the Implementation of the First Medium Term Plan
(2008 – 2012), Nairobi: Government of Kenya.
A. K. Mwenda
5
Preventable diseases/conditions continue to be the leading
causes of In-Patient Mortality for under fives in Kenya
Others
19%
Malaria
28%
Malnutrition
6%
Diarrhoeal
Diseases
7%
Volume
Depletion
10%
Respiratory
Infections
14%
Anaemia
16%
Source: Health Management Information System, 2008 as cited in RoK, 2011b. Health Situation Trends and Distribution 1994
– 2010 and Projections for 2011 - 2030. Nairobi: MoMS and MoPHS.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
6
Situational Analysis of Children and Women Health
• Nutrition:
– National prevalence rates of stunting , wasting and underweight
children have remained almost stagnant at approximately 35%, 7%
and 20% respectively.
– The national averages of children nutritional status also mask regional
disparities.
• Sanitation
– Most households (53.7% of the poor households and 40.2% of the
non-poor households) in Kenya use unsafe drinking water and live in
environments characterised by poor sanitation.
– Among the poor households only 1 in 5 access piped water, compared
to 2 in 5 non-poor households.
– Diarrhoea and intestinal worms infestation that are linked to unsafe
water, together accounted for approximately 10% of the outpatient
visits in 2008 (RoK, KDHS 2009).
A. K. Mwenda
7
Situational Analysis of Child and Women Health
• Immunisation
– Although, national immunisation coverage has increased from 57% in
2003 to 77% in 2008/09, poor health seeking behaviour and long
distances to health facilities have hindered the equitable coverage of
immunisation programmes. As a result, the country has not attained
the set target of 85%.
– National average mask significant regional disparities.
• Reproductive health care
– Although the country has a high coverage of Antenatal Care (92%),
only 44 percent of the deliveries are conducted under skilled care,
either by a nurse, midwife or a doctor.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
8
DATA AND METHODS
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
9
Data and Methods
• Qualitative and quantitative data
• Data verified by government officials – to confirm accuracy and
solicit explanation
• Assessment criteria:
– Adequacy of budgetary allocation by comparing country data to
international benchmarks and other countries
– Health sector allocative efficiency
• Criteria for identifying children’s programmes
– Relative impact on children compared to other population groups
– Programme that target women but have implication on the health of
children.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
10
RESULTS
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
11
Kenya lags behind comparable developing countries like
Rwanda and Botswana that spend more on healthcare
Public Health expenditure per capita (PPP US $), 2007
Per Capita Public Health Expenditure and Health Outcomes
600
500
BOTSWANA
400
SOUTH AFRICA
300
MALAYSIA
200
GHANA
100
RWANDA
INDONESIA
KENYA
UGANDA
0
0
5
10
15
20
TANZANIA
25
30
INDIA
35
-100
-200
40
45
R² = 0.3192
50
Children underweight for age (% aged under 5), 2006
Source: UNDP, 2009. Human Development Report and WHO, 2011, Data and Statistics, http://www.who.int/research/en/
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
12
Although the budget for the health sector increased in nominal
terms, as a share of total public expenditure it dropped from 7.4
percent in 2004/05 to 5.8 percent in 2008/09.
Sectors
2004/5
Productive sector
2005/6
2006/7
2007/8
2008/9
7.4
6.7
7.2
0.7
7.2
Public administration
10.4
11.9
14.5
18.7
9.5
Physical Infrastructure
13.5
14.6
17.7
20.6
25.9
Governance, Justice, Law &order
18.6
18.3
13.0
13.7
12.5
7.4
7.4
7.3
6.2
5.8
31.4
29.7
27.4
25.8
23.2
National Security
9.7
9.8
8.2
9.6
8.2
ICT
0.5
0.6
0.7
1.0
1.5
Manpower and special programmes
1.0
0.9
3.9
3.7
6.2
257,951
311,871
378,976
469,640
598,364
1.42
1.51
1.60
1.49
Health
Education
Total sectoral expenditure (Ksh Millions)
Health expenditure as % of GDP
Source: MoMS, 2009; MoPHS, 2009
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
13
Adequacy of Public Health care Spending
• At the current level of public spending on health care, financial targets have
not been achieved leading to a funding gap.
• As a result, the per capita total expenditure on health was US $ 105 in 2006,
falling short of the average for the Sub-Saharan Africa at US $ 147.8.
• The current public health care financing level is also way below the per
capita resource requirement for the Kenya Essential Package of Health
(KEPH) programmes estimated at US $ 35.2 in 2009/10 (Ministry of Health –
MoH, 2005a)
• Health sector development expenditure has been inconsistent and
unpredictable, reflecting the unpredictability of external financing and
regular economic shocks.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
14
Examples of KEPH services and charges: These charges,
though nominal may be the ‘difference’ between life
and death but most households can hardly afford.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
15
Adequacy of Public Health care Spending
• The Kenya government has aligned its health allocation with a pro-poor focus
by increasing spending for Primary Health Services (especially in health
infrastructure development)
• BUT there has not been commensurate increase in the budget allocation for
permanent employees and hence the ministries of health are not able to
attract and retain high calibre staff (there is 1 doctor for every 5,700 people in
Kenya).
• Accelerated development of health infrastructure is depleting common pool
resources available for the provision of other public services.
• Health ministries also face difficulty in procuring and sustaining adequate and
equitable provision of essential healthcare supplies and equipments.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
16
Public expenditure on children and women-related
programmes has been less than 10 percent of the total
public health sector expenditure.
Source: RoK, various. Printed Estimates of Recurrent Expenditures; RoK, various. Printed Estimates of Development
Expenditures.
KEPI – Kenya Expanded Programme on Immunization.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
17
Mismatch of children and women health care demands
and financing
• Nutrition: In 2007/08, less than 0.02 percent of health sector budget of
KSh. 25.6 billion was allocated to the Nutrition Division within the MoPHS.
In 2008/09, only 0.14 percent of the total health sector budget was
allocated to the Nutrition Division.
• Reproductive Health Care: A significant proportion (38.4% in 2005/6) of
the total reproductive health expenditure is borne by households through
the out-of-pocket OOP payments. In 2008/9, only 1.8 percent of the
overall government expenditure on health was spent on reproductive
health services.
• Immunization: Budget allocation for immunization programme did not
exceed 1 percent between 2003/4 and 2009/10.
• Sanitation: Management of sanitation and hygiene programme needs
better coordination across the several ministries involved.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
18
Child and women programmes over-rely on donor
funds which are unpredictable
Child and women
related programmes
(Figures in KSh millions)
2005/06
2006/07
2007/08
2008/09
2009/10
GoK Donor GoK Donor GoK Donor GoK Donor GoK Donor
Reproductive health
-
540
19
428
306
694
64
1,441
17
532
KEPI
-
52
41
132
587
-
434
202
462
-
Nutrition
-
-
-
137
-
-
-
-
-
135
592
60
697
893
694
498
1,643
479
667
Total
Source: RoK, various. Printed Estimates of development expenditure.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
19
Over 90% of donor funds are managed outsides the
mainstream government budget and are disbursed in
kind.
•
This denies the implementing agencies
–
–
The flexibility to determine the quality of goods and services delivered
Reduces the ability of agencies to respond to emergencies
Total Public Health Care Finance by Source, 2009/10
Source of Finance
MTEF Budget Sources (Includes donor on1 budget finance)
2 Donor Off-Budget Finance: Of which
a) USAID
b) Clinton Fund
c) DFID
d) Others (including UN)
3 User Fees
Total Public Health Finance
KSh
Billions
45.7
6.9
3.9
2.9
39.9
59.4
9
108.3
Source: Ministry of Medical Service (MoMS), 2010
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
20
Adequacy of Health Care Finance
•
The low per capita spending and heavy donor reliance as well as
inadequacies in the provision of health care services reflects a huge
financing gap in the health sector.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
21
User fees lower public health sector efficiency: Increase in
user fees in public sector facilities lowers utilisation of health care
services, diverts demand to private and mission facilities BUT does
not shift demand to traditional health care providers.
Elasticities of Health Care Utilisation in Kenya, 1994
(standard error in parentheses)
With respect to:
Private
GoK
User fee in GoK
facilities
Unavailability of drugs
in GoK facilities
0.109
(0.063)
0.152
(0.168)
0.076
(0.046)
0.559
(0.117)
Mission
SelfTreatment
0.039
0.0009
(0.147)
(0.007)
1.107
0.075
(0.317)
(0.018)
Source: Bedi et al, 2004, pp 29.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
22
Mechanisms through which user fees may lower
efficiency in the Public Health sector
• Leakage of revenue and therefore loss of opportunity to improve public
health care services (MOH, 2006).
• District Health Management Boards (DHMBs) do not have full authority to
determine the use of the funds they collect. They are required to submit
budgets to the headquarters for approval. As a result, DHMBs do not have
the incentives to improve their efficiency.
• Planning division of the ministry headquarters is not appropriately staffed
to effectively supervise and coordinate the collection of user fees.
• In some cases user fees waivers and exemptions are diverted to nondeserving patients, resulting in loss of opportunity to improve health care
delivery (MoH, 2006).
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
23
User fees enhance inequality in health care access: The
higher the proportion of financial burden imposed on patients by
cost sharing, the lower the chances of them accessing treatment.
OOP Expenditure on Health Care (Outpatient and Inpatient) as a % of HH Expenditure and the Proportion of
the Sick but Not Seeking Treatment, 2007.
14.00
12.00
20
10.00
15
8.00
10
6.00
4.00
5
2.00
0
OOP expenditure on health
care as a % of HH
expenditure
% reported ill but seeking
no treatment
25
0.00
Poorest
Second Poor
Middle
Second Rich
Richest
Expenditure Quintiles
% reported ill but seeking no treatment
OOP expenditure on health care (outpatient & inpatient) as a % of HH expenditure
Source: Authors construction based on HH Health Expenditure and Utilisation Survey Report 2007, RoK, 2009b
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
24
User fees enhance inequality in health care access:
User fees are a regressive mode of financing health care since
they impose disproportionately higher costs of health care on
the poor and the chronically ill.
1.80
1.60
1.40
6.00
1.20
1.00
0.80
0.60
4.00
5.00
OOP spending on
outpatient visits to
government facilities
Annual per capita
outpatient visits in
government facilities
Annual Per Capita Outpatient Visits to Government Facilities and the OOP Spending on Outpatient
Care as a % of HH Expenditure, by Expenditure Quintiles, 2007.
3.00
2.00
0.40
0.20
0.00
1.00
0.00
Poorest
Second Poor
Middle
Second Rich
Richest
Expenditure Quintiles
Annual per capita outpatient visits to government facilities
OOP expenditure on outpatient as a % of HH expenditure
Source: Author’s computation based on RoK, 2009b. HH Health Expenditure and Utilisation Survey Report 2007
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
25
DISCUSSION
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
26
Lessons
• Public health sector spending has been increasing but is still below the
recommended international standards and that of many comparable countries.
This limits access to health care among children and women.
• It is evident that majority of the patients in Kenya seek health care services in
government facilities. Naturally, therefore when funding for public health care is
disrupted:
– Household budgets are disrupted as many people seek health care services in the more
expensive substitute (private and mission) facilities.
– Alternatively, health care may not be viewed as a priority, leading to delayed treatment and
ultimately catastrophic health care costs
• Tax revenue and donor finance (as demonstrated above) are susceptible to
external shocks such as financial crisis, foreign exchange fluctuations, political
conflicts and climate change. These shocks in turn affect the sustainability of
health care financing.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
27
Lessons
• BUT children and women programmes rely heavily on donor financing
which is unpredictable and inadequate to fully fill resource gaps e.g. unfair
staffing.
• Households bear a significant proportion of the total health expenditure
owing to high user fees.
• User fees are a highly regressive mode of financing, requiring the poor and
the chronically ill to pay disproportionately higher amounts for health
care, than the rich. This limits access of health care services by certain
groups (especially children and women).
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
28
Some Proposals
•
The government should progressively increase budgetary allocations to children
and women programmes and reduce the programmes exposure to unpredictable
donor funding.
•
In order to enhance allocative efficiency, there is need to institutionalise district
consultations through the Social Budgeting Framework.
•
In order to tap into private sector finance and enhance efficiency in public health
care, government should forge partnerships with the private sector e.g. through
lease agreements for provision of health care supplies and equipments.
•
In the long run, the government should pursue policies that seek to eliminate user
fees for health care services, especially in facilities that are mostly used by the
poor.
•
In this regard, the government should consider expanding the social health
insurance coverage.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
29
Some Proposals
• Deepen the “Health Sector Services Fund (HSSF) ” components that are
meant to address ‘equity issues’ in health for children and women in
deprived communities and vulnerable populations. HSSF is an innovative
direct transfer of funds to dispensaries and health centres, started on
28th October 2010, with Ksh. 143 million disbursed to 590 health centres
across Kenya.
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
30
Thank you
By Albert Mwenda, Robert Peter Ndugwa,
Isa Achoba and Godfrey K. Ndeng’e,
31