Devolution and fresh funds should help improve access and indicators

Following decades of stagnation in basic health care indicators, Kenya’s health sector is slowly picking up. The government has found it challenging in the past to implement reforms aimed at reducing HIV/AIDS, improving maternal and child health, and combatting both communicable and non-communicable diseases (NCDs). Health care spending remains low, while key indicators such as maternal mortality have stayed high for a decade. Nonetheless, recent reforms have painted a brighter picture for health care in Kenya.

Efforts are coming from many angles. The country’s ongoing decentralisation, or “devolution” of certain authorities to the counties, is expected to improve equity, governance and access to basic services, while health policies have aimed at increasing foreign investment in hospitals, clinics and ICT upgrades. President Uhuru Kenyatta’s goal to deliver universal health care has seen the National Hospital Insurance Fund (NHIF) significantly expand its activities and coverage in the last year, raising hopes of coverage expansion for low-income people. Private institutions, meanwhile, are capitalising on Kenya’s steady economic growth and rising demand for health services and pharmaceuticals.

Oversight

The sector’s leading agency is the Ministry of Health (MoH). Formed as a result of a merger of the Ministry of Medical Services and the Ministry of Public Health and Sanitation in early 2013, the MoH sets policies, allocates resources and oversees eight semi-autonomous state bodies that deliver core services, including Kenyatta National Hospital, Moi Teaching and Referral Hospital, Kenya Medical Training College, Kenya Medical Supplies Agency, the Kenya Medical Research Institute, the NHIF, the National AIDS Control Council, and the HIV and AIDS Equity Tribunal.

As devolution progresses and authority shifts to the local level, county governors are becoming important decision-makers. In the devolved system, the MoH is charged with oversight, while county health departments are responsible for managing delivery. Many Kenyans see this as a solution to persistent regional disparities; however, preparedness is lacking in many counties, and building capacity will take time and investment.

Decentralisation has been in the works for decades. In 1992 the government set up district health management teams (DHMTs) with special advisory boards and charged them with overseeing public health services at the regional level, including supervisory support for low-level health facilities. Final decisions on budgets and resource allocations remained with the central authorities. However, the DHMTs failed to reach supervision targets, and budgetary remittances have often been irregular and behind schedule, the reasons commonly cited being lack of funds and transportation.

Plans & Policies

The draft Kenya Health Sector Strategic and Investment Plan (KHSSP) for 2012-18 proposes a three-pronged leadership framework, with the duties of stewardship divided among national health directorates, county health management teams and county facility management teams. Under the current framework, stakeholders have argued, the MoH maintains a dominant position in the sector, especially in formulating policy and planning.

County and national governments are nonetheless working together to achieve the goals outlined in the MoH’s chief policy document, the Kenya Health Policy 2012-30 (KHP). Specific spending policies are outlined under the KHSSP and the Medium-Term Expenditure Framework (MTEF) for 2014-17, which highlights six key targets including elimination of communicable diseases, reduction of NCDs, prevention of violence and injuries, and provision of essential health services.

Outside of the KHP, the MoH’s activities are shaped by a host of macro policies. First is the new constitution, which provides fresh mandates for health care that are driving legislation. Second, the country’s millennium development goals (MDGs) seek to quantifiably reduce extreme poverty and hunger, HIV/AIDs, and child and maternal mortality by 2015. Third, Vision 2030, the national economic development plan, aims to transform the country into an industrialised country by 2030, with development priorities segmented under three distinct pillars: social, political and economic.

Health care forms a key component of the social pillar, and the plan identifies a host of priority reforms including restructuring the sector’s leadership and governance, improving procurement of medicines and supplies, modernising health information systems and establishing equitable financing mechanisms, including social health insurance.

A series of five-year plans within the overarching KHP outlines specific strategies for achieving Vision 2030 targets. Kenya’s second Medium Term Plan (MTP), covering 2013-17, highlights the objectives of improving primary health care, increasing access to clean water and better management of communicable diseases. Other resources will go to reducing maternal and child mortalities as well as NCDs. The MTP also includes initiatives to encourage private investment in medical research, drug-making and modern hospital care.

In May 2014 Kenya’s parliamentary committee on health kicked off a three-day meeting for a final review of the new Kenya Health Policy, which will provide the framework for health sector operations in 2014-30, replacing the current one for 2012-30. Stakeholders are also reviewing the draft Kenya Health Bill, which would establish the legislative environment needed to support the constitution’s health-related provisions and form the foundation for related legislation.

Spending & Service Delivery

The sector has expanded rapidly in the past 15 years, with the total number of health facilities more than doubling from 4294 in 1999 to 9448 in 2013. Much of this growth has come from the private sector – indeed, private ownership of health facilities rose from 48% in 1999 to 53% in 2013. The private sector also accounts for more than half of spending: between 1995 and 2011, the average total health expenditure per year was 4.4% of GDP, of which 1.9% was public and 2.5% was private.

This shift in ownership is partly a function of consistent under-funding for public health care in Kenya. A 2013 report by KPMG called “Devolution of Health care Services in Kenya: Lessons learnt from other countries” found that in the past four years, the state allocated 4% of GDP to health care, although the UN’s 2013 human development index (HDI) reported a figure of around 2% in 2010 and 2011.

As a signatory to the 2001 Abuja Declaration, Kenya is committed to allocating at least 15% of its national budget to health in line with its MDGs. Since then, however, health spending has remained at less than 10% and dwindled in the years to 2013. In a 2011 World Health Organisation (WHO) report, “Abuja Declaration 10 years on”, Kenya ranked among the 27 countries that had made insufficient progress, and was one of only five that had actually reduced their budgetary allocation to health. In the KPMG’s regional comparison of the total health budget as a portion of GDP, Kenya ranks last, behind Rwanda, Tanzania and Uganda.

In the 2013/14 budget, the MoH was allocated KSh36bn ($410.4m), a 59% decrease from KSh87.8bn ($1bn) in 2012/13. This reduction was attributed to devolution, with county governments allocated KSh64bn ($729.6m) for health care programmes to bring total health care spending to KSh100bn ($1.14bn), according to the government’s 2014/15 budget statement. With total spending at KSh1.44trn ($16.42bn) and GDP at an estimated $39.1bn in fiscal year 2013/14, health spending still represented just 6.9% of total spending and 2.9% of GDP, well below the Abuja target.

In the 2014/15 national budget, the MoH has been allotted KSh47.36bn ($539.9m) a significant increase on 2013/14. Of this, KSh9.59bn ($109.33m) is allocated to preventative services, KSh18.97bn ($216.26m) to curative services, KSh4.77bn ($54.38m) to research and development, and KSh4.31bn ($49.13m) to maternal and child health programmes. Although county allocations for health were not specified in the budget statement, total expenditure in 2014/15 has been pegged at KSh1.54trn ($17.56bn), meaning Kenya would need to allocate $2.64bn to health, or an additional $2.1bn to county governments, to meet the Abuja target. This is unlikely given the government’s current focus on infrastructure, education and agriculture.

Private Funding

Outside of public funding, health care needs are met by three segments of the private sector: fixed-base operators (FBOs), NGOs and private investors. According to a 2014 report by Cardno Emerging Markets and Oxford Policy Management, FBOs run nearly one-quarter of all health facilities in Kenya under three main umbrella organisations: namely, the Christian Health Association of Kenya (CHAK), the Kenya Episcopal Conference (KEC) and the Supreme Council of Kenya Muslims (SUPKEM). CHAK’s network comprises 307 medical health units across four regions, while KEC focuses its activities at a grassroots level through 465 health units (45 hospitals, 92 health centres, 282 dispensaries and 46 community-based health workers) and coordinates 13 nurse training colleges and one clinical medical college. SUPKEM provides curative and preventive services through a network of 25 clinics.

Kenya’s NGO sector is also highly involved in health care service delivery, which is largely a result of donor support for programmes that deal with HIV/AIDS, malaria, tuberculosis and family planning.

According to estimates from the Health NGOs Network’s Best Practices Technical Working Group, Kenya’s health care sector has more than 6000 NGOs, notably the UN’s Population Fund, the International Children’s Emergency Fund, the Joint Nations Programme on HIV/AIDS, the World Bank Group and the WHO, as well as a variety of national development agencies from Denmark, the EU, Germany, the US, Japan and the UK.

Important Indicators

In the UN’s 2013 HDI report, Kenya slid two places, from 143rd to 145th out of 187 countries. The UN attributed this to changes in survey methodology, although Kenya has long been on the low end of the list. Life expectancy is now 57.5 years, the same level as in 1980, and dipped as low as 53.1 in 2005.

The leading causes of death in Kenya are HIV/AIDS, perinatal conditions, lower respiratory infections, malaria and tuberculosis; meanwhile, NCDs such as diabetes, cancer, cardiovascular disease and high blood pressure are on the rise. The WHO reports that HIV/AIDS causes the most deaths in Kenya, accounting for 29.3% of the total. According to the HDI, the prevalence of HIV among youth stands at 4.1% for females and 1.8% for males; according to the UN, close to 1.2m Kenyans are living with the disease, with a prevalence of 6.9% for women and 4.4% for men.

The government has channelled significant efforts into preventing new cases of HIV/AIDS while delivering antiretroviral (ARV) medications to those already infected. In its 2014/15 budget, it reported that the number of patients on ARVs rose from 250,000 in 2008 to 620,000 in 2013. HIV prevalence fell from 7.2% to 5.6% between 2007 and 2012, the UN reported in 2013. The country’s HIV-prevention initiatives include male circumcision, testing and counselling campaigns, and programmes to prevent transmission from mother to child. However, according to the National AIDS and Sexually Transmitted Infections Control Programme, some 80% of Kenya’s HIV programmes are externally funded, which could pose problems to long-term treatment.

Middle-Income Statuus

In September 2014 Kenya revised its method for calculating GDP, elevating it to middle-income status as of 2014. While this is good news for businesses seeking investment, it is worrying for sectors that rely on donor funds. Stakeholders fear that such support will be scaled back, bringing new challenges for preventing and treating HIV/AIDS. “This has implications for the health sector because some donors will withdraw support should the country reach middle-income status, as the programmes delivered will not be viewed as quite so critical,” Thomas Maina, senior health finance advisor at the USAID- and Futures Groupfunded Health Policy Project, told OBG. “We have managed to flatten the curve of HIV prevalence, but now we must look inwards and seek local solutions,”

Maternal Mortality

Poor maternal and child health remains a big problem in Kenya. Most maternal deaths occur during or immediately after childbirth, usually from bleeding, high blood pressure, prolonged or obstructed labour, infections and unsafe abortions. According to the MTP, half of mothers in Kenya are anaemic, and the presence of skilled attendance at delivery stands at 46%. Contraceptive usage is also low, at 46%, while Kenya’s population growth and fertility rates are high, at 2.7% and 4.7%, respectively.

Kenya’s maternal mortality rate (MMR) has improved little over the past decade. Measured per 100,000 live births, this indicator reached 488 in 2008 (some regions reported as high as 1000), up from 414 in 2003, if lower than the 590 reported in 1998. Recent statistics on MMR vary greatly: 360 in 2012 according to the HDI; 400-500 in June 2013 according to the MoH; and 488 as of 2012 according to the MTP. Whatever the true figure, Kenya is unlikely to meet its MDG of reducing this to 147 per 100,000 live births by 2015, although the MTP target is 300 by 2015 and 150 by 2017.

Child malnutrition also remains a serious challenge. According to the MTP, stunting levels stand at 30% of under-fives. Meanwhile, 40,000 children die a year from being underweight, Vitamin A deficiencies and wasting. This danger is particularly acute for those in areas where food has been chronically insecure.

In 2013 President Uhuru Kenyatta announced that maternal health care services would be made available free of charge. For this purpose, the government allocated KSh4.5bn ($51.3m) in 2013/14 and KSh4.04bn ($46.06m) in 2014/15, according to its budget statements. When the programme launched in June 2013, hospitals reported a massive influx of patients, and while the move is expected to improve MMR and neonatal mortality rates, some health care providers say that their already-strained facilities are unable to meet the new demand. “MMR remains high because mothers are not delivering in hospitals due to the high cost of care,” Eulalia Namai, a former health information and promotion officer at the WHO, told OBG. “Provision of free maternal health is a step in the right direction, but expanding service offerings and hospital capacities will be critical to reducing child and maternal deaths.”

Another initiative, the “Beyond Zero” campaign led by the first lady, Margaret Kenyatta, was launched in 2014 to speed up implementation of the national plan to eliminate new HIV infections among children. First unveiled on World AIDS day in 2013, the campaign aims to galvanise high-level leadership on this issue focusing on five key areas: accelerating HIV programmes; encouraging investment in maternal and child health; mobilising partners; involving communities to address barriers to accessing services; and providing accountability and recognition in the endeavour to combat these issues. So far, it has attracted funds from donors and private sector organisations to purchase mobile clinics that are designed to provide integrated HIV care and maternal and child health outreach services.

New Disease Burden

The growing prevalence of NCDs is also a cause for concern. A 2013 report by the Kenya NCD Alliance, “Case Kenya Study: The NCD Situation”, found that these cause 21.6% of male deaths and 22.3% of female deaths in Kenya, led by circulatory diseases, cancer and diabetes. The report also found that 32.2% of school children and 53% of college students are smokers, lifting the overall smoking rate to 26%. This and poor air quality in urban centres has contributed to a rise in respiratory diseases.

Stakeholders now worry that, with the prevalence of infectious diseases already high, the rising incidence of NCDs has created a dual burden that could overwhelm already-strained facilities. This situation has opened new doors for private sector investment in treatment and prevention of NCDs, generally a more profitable segment of health care service delivery (see analysis).

Universal Healthcare

With more than 30% of medical expenses in Kenya paid out of pocket, the Kenyatta administration has made universal health care a key priority. Health financing policies have been revised many times in the past 50 years in an effort to achieve this, but legislative reforms have hit snags and delays.

The NHIF is now seen as the best conduit for expanding health coverage to all citizens. Established in 1966 as a department of the MoH, the fund was initially mandated to provide accessible health insurance for salaried public and private sector employees earning at least KSh1000 ($11.40) a month. Since then, it has been reformed several times to include more benefits, target informal households and add outpatient care.

In 1998 the NHIF Act No 9 was passed, repealing and replacing all previous laws and transforming the NHIF into an autonomous state company managed by a board of directors. As a result, the fund currently offers mandatory inpatient insurance to all formal sector employees, inpatient insurance coverage to informal sector workers on a voluntary basis and outpatient coverage to civil servants. The government has also been moving to expand coverage to low-income Kenyans in recent years, offering family premiums for KSh160 ($1.82) a month to informal and low-earning workers.

The most significant expansion of coverage occurred in October 2012, when the NHIF partnered with the Rockefeller Foundation to invest KSh23bn ($262.2m) in rolling out a free insurance scheme to 9m low-earning Kenyans. This coverage includes general consultation, laboratory tests, drugs, X-rays, ear-nose-and-throat services, diagnosis, clinical counseling and treatment for HIV, diabetes and asthma.

As of 2014 the NHIF’s principal contributors numbered 4m, with coverage extending to 15m Kenyans. This still represents just 34.2% of the total population, compared to 56% coverage in Ghana and 70% in Rwanda. The NHIF hopes to expand cover to 25m Kenyans by 2016 mainly by targeting informal workers outside of major urban centres. “We’re engaging with clients at the county level right now and working with governors to establish field offices,” Lawrence Kibare, senior assistant manager of communications at NHIF, told OBG. “The challenge is more to do with administration of services, because we know the demand is there.”

The 2014/15 health budget focuses on scaling up policy interventions that enhance equitable health care. Similar to its free maternal care programme, the idea is to increase access to primary care in public health centres and dispensaries by removing user fees. The government’s plan is to improve and equip all public health facilities over the next decade at an estimated cost of KSh45bn ($513m). Together with fresh private investment in hospitals and clinics, such measures should expand comprehensive health coverage considerably in the coming years (see analysis).

Human Resources

Kenya is among the countries the WHO identifies as having a “critical shortage” of health care workers. Kenya has an average of 19 doctors and 173 nurses per 100,000 people, compared to WHO recommended minimum staffing levels of 36 and 356, respectively. According to the MTEF, the optimal sector staffing requirement is 72,234. The sector currently has 59,667 approved positions, of which 49,096 positions are filled, leaving 10,371 vacant. This shortage is exponentially worse in remote rural areas, where Transparency International has documented under-staffing levels of 50% to 80% at some facilities.

The government has made a concerted effort to increase these levels. Between 2011 and 2013, it claims to have recruited 2100 doctors, 10,087 nurses, 2093 community health extension workers and 776 public health workers. Despite these new hires, however, the absolute number of trained health care personnel as a ratio of the population continues to be very low.

Outlook

While there is plenty of room for improvement in the health care sector, the growing role of the private sector and new reforms aimed at expanding access and service through decentralisation should have a profound impact. As the private sector expands its participation in service delivery, the government will be better able to shift its efforts towards providing essential services, and this should help reduce the disease burden and improve basic indicators in line with Vision 2030 development targets. Though underfunding has plagued the sector for decades, devolution and new foreign investment, coupled with an expanded NHIF coverage, should see Kenya’s global health care ranking improve considerably in the medium term.