Moving toward UHC Kenya NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND THE ROLE OF COLLABORATIVE ACTIVITIES Moving toward UHC: Kenya Kenya’s snapshot 1 Kenya’s snapshot Existing national plans and policies to achieve UHC 2 56+44+C Key challenges on the way to UHC 4 UHC Service Coverage Results of Joint External Evaluation Collaborative efforts to accelerate progress toward UHC 6 Index (SDG 3.8.1, 2015) of core capacities for pandemic preparedness (JEE, 2017) 56% References and definitions 8 Score (for capacity) # of indicators (out of 48) 5 Sustainable 0 4 Demonstrated 7 Catastrophic OOP health expenditure incidence at the 10% threshold 3 Developed 15 (SDG 3.8.2, 2005) 2 Limited 22 5.8% of households 1 No capacity 4 Health results Performance of service delivery – selected indicators LMIC Maternal Mortality Under-Five Mortality (PHCPI, 2013-2015) Kenya average Ratio (WHO) Rate (WHO) Per 100,000 Live Births Per 1,000 Live Births Care-seeking for symptoms of pneumonia 65.7% 61.5% Dropout rate between 1st 687 and 3rd DTP vaccination 7.3% 7.5% 510 Access barriers due to 102 treatment costs 36.7% 47.4% 49 Access barriers due to distance 22.7% 35.8% 1990 2015 1990 2015 70 (SDG target) 25 (SDG target) Treatment success rate for new TB cases 87% 80.1% Life Expectancy Wealth Differential at Birth (WHO) in Under-Five Mortality (PHCPI, 2008) Provider absence rate 27.5% 28.9% Caseload per provider 15 9 27.8 per day per day 63 52 More deaths in Diagnostic accuracy 72.2% 47.9% lowest than highest wealth quintile Adherence to 2000 2015 per 1,000 live births clinical guidelines 43.7% 33.6% See page 8 for References and Definitions. 1 Moving toward UHC: Kenya Moving toward UHC: Kenya Existing national plans and policies to achieve universal health coverage (UHC) SERVICE DELIVERY REFORMS HEALTH FINANCING REFORMS In line with the Constitution of Kenya (2010) The government of Kenya has instituted and Kenya Vision 2030 long-term development a number of reforms to improve health goals, Kenya is committed to achieving financing and financial protection. These UHC and providing quality health care for include: all. The Kenya Health Sector Strategic and Investment Plan 2014–18 defines health system • National Hospital Insurance Fund (NHIF): strengthening priorities to achieve these Established in 1966, this currently covers objectives. Key investments are necessary to (i) both formal and informal workers (20% build a robust and resilient health system that of the population). The government has can withstand the shocks of disease outbreaks revised the contribution rates for the and address the epidemiological transition, first time in 25 years and expanded the and (ii) ensure critical enhancements in health benefit package to include outpatient information systems to measure health system services as well as coverage for selected performance as well as generate data for noncommunicable diseases. evidenced-based reforms. • Health Insurance Subsidy for the Poor To enable Kenyans to realize their (HISP): To extend financial protection to constitutional right to health, the government Kenya’s poorest citizens, the government of Kenya (GoK) is prioritizing universal access launched the HISP pilot in 2014. This to primary care with a focus on reproductive, program provides a comprehensive maternal, and newborn health services. An package of outpatient and inpatient essential package defines services that should services to the neediest families in Kenya, be available to the population, and efforts both in public and accredited private • Free maternity services and removal of user counties as part of their equitable share of have been made in recent years to broaden the facilities. fees at the primary level. The government national revenue. Counties are now responsible range of services. The GoK has also invested has also removed user fees in all public for deciding how much to allocate to the health in the District Health Information System 2 • Health Insurance Programme for the dispensaries and health centers, and sector and how to spend these resources in the (DHIS2) platform, which is the main database Elderly & People with Disabilities: This maternity services are provided for free delivery of health services. where both private and public health facilities scheme is based on a cash transfer in public and contracted private facilities are required to enter monthly data on service program. An annual budgetary allocation (both for-profit and not-for-profit). The Health Act passed in 2017 aims to further delivery. Information can be analyzed and of 500 million Kenyan shillings is streamline service delivery systems, and aligned with other databases and sources of provided by the government to purchase GOVERNANCE REFORMS there is significant emphasis on coordination information (for example, the World Bank SDI health insurance coverage through Kenya has recently gone through a rapid between the national government and county program) to track progress. There have been the NHIF. Beneficiaries are entitled to devolution. The Constitution of Kenya health systems. The Act also provides for the efforts to introduce electronic systems at the a package similar to those of formal devolved power and accountability to deliver establishment of public-private partnerships in point of care to streamline management and employees covered by the NHIF. essential health services to its 47 county the health sector and for financing to support make information on quality of care available. governments and provided for transfer of progressive financial access to UHC, while ring about two-thirds of the health budget to fencing the funds for health. 2 3 Moving toward UHC: Kenya Moving toward UHC: Kenya Key challenges on the way to UHC WEAKNESSES AND BOTTLENECKS priority diseases; indicator- and event-based provides conditional grants to counties with Health Management Information Systems IN SERVICE DELIVERY surveillance systems; analysis of surveillance level 5 hospitals to compensate for services (HMIS). In Kenya, as in many low and middle Coverage of essential health services. Although data; and national vaccine access and delivery. rendered to people from other counties; income countries (LMICs), the HMIS is not fully Kenya has shown improvement in the coverage This evaluation also emphasized continued however, compensation is far below past levels developed and does not allow for full monitoring of essential health services, important gaps challenges in a number of areas, including and does not match actual needs. In addition, and assessment of progress. Household surveys persist. Disparities between urban and in preparedness; notably, Kenya lacks a other conditional grants from the national provide population-level estimates and enable rural communities are stark for access to multi-sectoral and multi-hazard public health government, including reimbursements for disaggregation by socioeconomic status, but family planning, antenatal care services, and emergency plan, which could guide efforts to removing user fees in primary care facilities are periodic and expensive. In addition, facility vaccination coverage, which remains too low bolster both public and animal health systems and providing free maternity services—initially surveys are carried out to provide the full overall. These gaps underscore the need for against the threat of disease outbreaks and channelled directly to facilities—are currently picture of service provision at the facility level. increased investments in service delivery and pandemics. A wide array of recommendations transferred through the county revenue fund Although these databases and surveys provide broader coverage to promote greater equity in is proposed, including fast-tracking the (CRF). Such an arrangement, although aligned useful data, better value could be generated access to care. completion, testing, and dissemination of the all to the country’s Public Financial Management by integrating and strengthening capacity for hazards plan aligned with the National Disaster Act and the Constitution, potentially leads timely generation and use of quality data. Quality of care. The World Bank (WB) Service Management Unit’s Emergency Response Plan. to delays in funds transfers and undermines Delivery Indicators (SDI) program (2013) service delivery. showed high provider absence (28% on average) HEALTH FINANCING CHALLENGES from health facilities and low adherence to Public health expenditure, as of 2012–13, was clinical practice guidelines, including for 6.1% of total government expenditure (Kenya the management of maternal and neonatal National Health Accounts, 2012–13), which is complications (only 44% of providers followed still comparatively low. While the government the guidelines approved by the World Health contribution has increased, available resources Organization). In addition, there were deficits remain limited vis-a-vis current and future in commodities and infrastructure: essential needs. Out-of-pocket (OOP) payments are a drugs were available in only 67% of facilities; a major barrier to access and push close to two fourth of all facilities lacked minimum pieces of million Kenyans into poverty. Co-payments do basic equipment such as a thermometer, scale, not reflect patients’ ability to pay. Fragmented or sterilization equipment; and almost half of health financing arrangements create dispensaries lacked basic infrastructure (clean challenges for pooling, increase costs for water, adequate sanitation, and electricity). administration, and incentivize inefficiencies. Purchasing arrangements are largely passive; Pandemic preparedness. While pandemic there is no purchaser-provider split and provider preparedness in Kenya is relatively advanced, payments are ill defined. Kenya has a wide range of challenges, as demonstrated through the Joint External GOVERNANCE CHALLENGES Evaluation (JEE) conducted in March Challenges linked to devolution. Devolution 2017. The JEE revealed strengths in areas presents significant governance challenges for such as: laboratory testing for detection of the health sector. The national government 4 5 Moving toward UHC: Kenya Moving toward UHC: Kenya Collaborative efforts to accelerate progress toward UHC EXISTING INITIATIVES SUPPORTED of maternal mortality. This initiative focuses on BY EXTERNAL PARTNERS improving health systems to deliver integrated There are several partners engaged in Kenya reproductive, maternal, newborn, child and to support the attainment of UHC, including adolescent health (RMNCAH), with a focus building resilient health systems and on referral systems, demand creation for strengthening monitoring and evaluation of utilization of RMNCAH services, improving health system performance. These partners quality of care through routine inspection and providing support to the government of supervision, nursing and midwifery trainings, Kenya include the Tokyo Joint UHC Initiative, and improvement of vital statistics. supported by the government of Japan and led by the World Bank (WB), in collaboration with The Global Financing Facility (GFF), a multi- the Japan International Cooperation Agency stakeholder country-led partnership, is working (JICA), the United Nations Children’s Fund with key stakeholders to improve coordinated (UNICEF), and the World Health Organization investments in RMNCAH and monitor results. (WHO). Additionally, the U. S. Agency for The GFF uses RMNCAH as an entry point to International Development (USAID), the UHC by ensuring that all women, children, and German Agency for International Cooperation adolescents can have healthy and productive (GIZ), the German Development Bank (KfW), lives and aims to align donors around the PLANS FOR FUTURE and the Korean government are all significant shared vision of UHC. The GFF also supports COLLABORATIVE WORK plan, which will provide a framework for how partners in this agenda. domestic resource mobilization through the Kenya can increase investments in both public GFF Trust Fund cofinanced project, encouraging Policy and Human Resources Development and animal health to ensure that it is better Existing initiatives also include the UN H6 county governments to allocate at least 20% of (PHRD)-funded advisory support prepared to prevent, detect, and respond initiative in counties with the highest burden their budgets to health. In Kenya, the joint work under the Tokyo Joint to disease outbreaks and pandemics. This UHC Initiative will focus primarily on two key activity will also involve the establishment of a areas. The first area is addressing key gaps national multi-sectoral governance framework in HMIS by undertaking a combination of to improve national- and county-level advisory and analytical services to inform the capacity for coordinating and implementing The Health Act passed in 2017 aims to further streamline design of a strengthened and better integrated the plan. Furthermore, the joint work will service delivery systems, and there is significant emphasis on monitoring and evaluation system. Activities closely cooperate with other investments in will include: a critical analysis of various routine health, such as the Global Fund and Gavi, to coordination between the national government and county and nonroutine HMIS and other data sources contribute to health system strengthening. health systems. The Act also provides for the establishment from an interoperability perspective; analytical Considering that other sectors such as work and advisory services to inform the design nutrition and water and sanitation compose of public-private partnerships in the health sector and for of an interoperability platform; and knowledge the foundations of heath for all, challenges in financing to support progressive financial access to UHC, sharing and dissemination. The second area is strengthening health system resilience through these fields also will be considered under the joint work. Future efforts can build on initial while ring fencing the funds for health. support to the government to develop and cost work, to generate evidence for mobilizing the first multi-sectoral pandemic preparedness resources, including under IDA 18. 6 7 Moving toward UHC: Kenya References & Definitions (page 1 indicators) UHC Service Coverage Index (2015) – Life Expectancy at Birth (2000-2015), WHO/World Bank index that combines 16 Maternal Mortality Ratio (1990-2015), tracer indicators into a single, composite Under-five Mortality Rate (1990-2015) – metric of the coverage of essential health WHO Global Health Observatory: services. For more information: WHO/World http://apps.who.int/gho/data/node.home Bank (2017). Tracking UHC: Second Global Monitoring Report. Wealth Differential in Under-five Mortality (Single data point, year varies by country) Catastrophic out-of-pocket (OOP) health – Indicator used by the Primary Health Care expenditure incidence at the 10% threshold Performance Initiative (PHCPI) to reflect equity (Single data point, year varies by country) – in health outcomes. For more information: WHO/World Bank data from Tracking UHC: https://phcperformanceinitiative.org/indicator/ Second Global Monitoring Report (2017). equity-under-five-mortality-wealth-differential Catastrophic expenditure defined as annual household health expenditures greater than Performance of service delivery – selected 10% of annual household total expenditures. indicators (Single data points, years vary by country) – Indicators used by the Primary Health Results of the Joint External Evaluation of Care Performance Initiative (PHCPI) to capture core capacities for pandemic preparedness various aspects of service delivery performance. (2016/17, year varies by country) – A voluntary, PHCPI synthesizes new and existing data from collaborative assessment of capacities to validated and internationally comparable prevent, detect, and respond to public health sources. For definitions of individual indicators: threats under the International Health https://phcperformanceinitiative.org/about-us/ Regulations (2005) and the Global Health our-indicators#/ Security Agenda. 48 indicators of pandemic preparedness are scored using five levels (1 is no capacity, 5 is sustainable capacity). https://www.ghsagenda.org/assessments Photo credits: Page 3: Flore de Preneuf / World Bank Page 5: Peter Kapuscinski / World Bank Page 6: Curt Carnemark / World Bank Co-authored by: 8